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Full text of "Nutrition and clinical dietetics"

MEMCAL tS 




'illiam B.Lei^itt, I.LD 
Memorial 







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Nutrition and Clinical 
Dietetics 



BY 

HERBERT S. CARTER, M.A., M.D. 

ASSOCIATE IN CLINICAL MEDICINE, COLUMBIA UNIVERSITY*, ASSOCIATE ATTENDING PHYSICIAN 

TO THE PRESBYTERIAN HOSPITAL; CONSULTING PHYSICIAN TO THE LINCOLN 

HOSPITAL, NEW YORK 



PAUL E. HOWE, M.A., Ph.D. 

ASSISTANT PROFESSOR OF BIOLOGICAL CHEMISTRY, COLUMBIA UNIVERSITY, NEW YORK 



HOWARD H. MASON, A.B., M.D. 

INSTRUCTOR IN DISEASES OF CHILDREN, COLUMBIA UNIVERSITY, NEW YORK; ASSOCIATE 

ATTENDING PHYSICIAN TO THE PRESBYTERIAN HOSPITAL; ATTENDING PHYSICIAN 

TO THE RUPTURED AND CRIPPLED HOSPITAL, NEW YORK 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
I917 



Copyright 

LEA & FEBIGER 

1917 



T? /A 2-/6 
CS2. 
1917 

copy Z 



PREFACE. 



In presenting this book the authors are conscious of the fact 
that dietetics is far from a mature science and that a book 
founded entirely on facts proved in the laboratory is as yet 
impossible. So much scientific progress has been made with 
regard to the nature of food and its utilization and require- 
ments in health and disease, that were feeding merely a matter 
of food reactions, analogous to test-tube reactions, it would 
be a comparatively simple matter to prescribe a diet. In deal- 
ing with all things human, however, the personal equation 
is of immense importance and one can never foreknow how a 
food will affect different people under apparently similar con- 
ditions. It is on this account that accurate clinical observa- 
tion will always be a prime factor in the successful feeding of 
patients. Not only should the probable effect of food under 
particular circumstances be known, but any variation there- 
from should be met by an experience wide enough to indicate 
in which direction the next move may be made. So it is that 
dietetics must be deduced in part from an accurate knowledge 
of the chemistry of foods and of nutrition and in greater 
degree from a knowledge painfully acquired by previous experi- 
ence in somewhat similar circumstances. It is also a fact that 
the same goal may often be reached by several roads, so that 
in most conditions different men may attain the same or almost 
similar ends by different methods; however, the principles 
underlying their efforts must be in accord. 

In choosing data from the literature of dietetics it has been 
the aim of the authors to use only the more recent statements 
from reliable sources, the seeming exceptions only occur when 
facts or statistics of an earlier date have not been superseded 
by later investigation. The attempt has also been made to 
present the etiological factors of the disease under discussion 



i\ 



iv PREFACE 

in order to make the rational use of foods depend on these, as 
well as on knowledge of nutritional chemistry. Metabolism, 
in its broader aspects, has been discussed in each disease when 
enough is known to make such consideration profitable. The 
symptomatology and treatment of disease, other than by diet, 
have not been given except insofar as it has been necessary 
to do so in the interest of a better understanding of the case 
or where general or special treatment has been indissolubly 
bound up with the use of diets. 

No attempt has been made to go into the question of diets 
for special conditions such as for the Army, Navy, Hospitals, 
Alms Houses, etc. The requirements for food under different 
conditions of muscular activity being known, each must have 
its dietary worked out on this basis. Diets already in use for 
such conditions may or may not be adequate for this purpose 
under other circumstances. Hence a repetition of these 
various dietaries would not be profitable. 

The authors wish to make grateful acknowledgment to 
Professors L. Emmett Holt, W. J. Gies, W. T. Longcope of 
Columbia University and Dr. E. F. Du Bois, for their sugges- 
tions and criticisms of material presented. To Dr. T. C. 
Janeway for permission to use certain diet lists, and to Dr. 
Irving Fisher and Dr. Alida F. Pattee for permission to use 
their tables on food values, to Dr. H. C. Sherman, Mrs. Mary 
Swartz Rose and to the Macmillan Company for the use of 
data contained in The Chemistry of Food and Nutrition, 
Food Products and Feeding the Family. Acknowledgment 
should also be made to the Washington University for the 
use of the library allowed one of the authors. 

H. S. C. 
P. E. H. 

New York, 1917. H. H. M. 



CONTENTS. 



Introduction 17 



PART I. 
FOODS AND NORMAL NUTRITION. 

CHAPTER I. 

Digestion, Absorption and Excretion. 

Digestion 23 

Enzyme Action ■ 23 

Oral Digestion 25 

Gastric Digestion 27 

Intestinal Digestion 32 

Absorption 33 

Bacterial Action and Feces 38 

Intestinal Bacteria 38 

Putrefaction and Feces 40 

Excretion • . 43 

Digestibility of Food 47 

CHAPTER II. 

Energy Requirement. 

Caloric Value of Food-stuffs 51 

One Hundred Calory Portion 52 

Determination of Energy Requirement 53 

Respiration Apparatus 54 

Respiratory Quotient 55 

Basal Energy Requirement 56 

Body Surface as Unit of Reference 59 

Calculation of Energy Requirement 59 

CHAPTER III. 

Protein Requirement. 

Standard Dietaries — Average Protein Requirement 66 

CHAPTER IV. 

Inorganic Salts and Water. 

Chlorine Requirement of Man 77 

Phosphorus Requirement of Man 82 



vi CONTENTS 

Calcium Requirement of Man 85 

Iron Requirement of Man 88 

Iodine Requirement of Man 90 

Water Requirement of Man 91 

Vitamines and Accessory Food-stuffs 94 

Fasting 98 

CHAPTER V. 

Normal Feeding and Food Economics. 

Requisites of a Complete Diet 102 

Suggested Menus 106 

Factors which Determine the Cost of Food iii 

Unbalanced Diets 117 



PART II. 
FOODS. 

CHAPTER VI. 

Introduction — Milk. 

Milk 122 

Chemical Properties; Protein 124 

Fats 125 

Carbohydrates; Salts 125 

Variations in Composition; Influence of Temperature upon Milk . . 127 

Action of Bacteria; Action of Heat 129 

Digestion of Milk 130 

CHAPTER VII. 

Protein Foods. 

Sources of Protein Food 132 

Protein Classification • • I35 

I. Simple Proteins 135 

Albumins; Globulins 135 

Glutelins; Alcohol Soluble Proteins (Prolamines); Albumin- 
oids; Histones; Protamines 136 

II. Conjugated Proteins 136 

Nucleoproteins; Glycoproteins; Phosphoproteins; Hemoglo- 
bins; Lecithoproteins 137 

III. Derived Proteins 138 

A. Primary Protein Derivatives 138 

Proteins: Metaproteins; Coagulated Proteins . . 138 

B. Secondary Protein Derivatives 138 

Proteoses; Peptones; Peptides 138 

Influence of Heat 138 

Effect of Low Temperatures 139 

CHAPTER VIII. 

Meat or Flesh Food. 

Value of Diet 144 

Composition 145 



CONTENTS vii 

Influence of Temperature . . . . " 146 

Cooking 146 

Digestibility of Meat v 149 

Meat Preparations 152 

Meat Extracts 152 

Meat Juices; Meat Broths . 154 

Gelatin 155 

CHAPTER IX. 

Fish and Shell Fish — Poultry and Game. 

Fish and Shell Fish 156 

Cold Storage Fish; Preserved Fish; Cooking of Fish 159 

Digestibility of Fish 160 

Poultry and Game . 160 

CHAPTER X. 

Eggs and Cheese. 

Eggs 162 

Egg White; Egg Yolk 163 

Cooking of Eggs 164 

Digestibility of Eggs • 165 

Preserved Eggs 166 

Egg Substitutes 167 

Cheese 167 

Digestibility of Cheese; Casein Preparations 168 

CHAPTER XL 

Protein-rich Vegetable Foods. 

Legumes in General 169 

Soy Bean 171 

Peanut; Preparation of Legumes 172 

Nuts 173 

CHAPTER XII. 

Carbohydrate-rich Foods. 

Sugars .'..... 175 

Sucrose 175 

Glucose; Lactose; Maltose 176 

Maple-sugar; Invert sugar; Fructose 177 

Digestion and Utihzation of Sugar 178 

Starch-rich Foods 179 

Grains and their Products 181 

Barley; Buckwheat 182 

Corn 183 

Oats; Rice 184 

Rye 185 

Wheat 185 

Bread 187 

Baking Powders 188 

Rolls, Biscuits, Muffins, etc.; Biscuits, Crackers; Cakes; Break- 
fast Foods 189 

Macaroni 190 

Celluloses 190 

Potatoes 191 



viii CONTENTS 



CHAPTER XIII. 

Fat-rich Foods. 

Cream 198 

Butter 198 

Renovated Butter and Butter Substitutes 200 

Oleomargarine 200 

Lard 201 

Cotton Seed Oil 202 

Olive Oil 203 

Cod-liver Oil 203 

CHAPTER XIV. 
Foods Valuable for their Salts, Water, and Bulk. 

Fruits and Vegetables 204 

Cooking of Vegetables and Fruits 208 

Food Adjuncts 210 

Spices 210 

Flavoring Extracts; Meat Extracts; Vinegar; Sugar and Salt (Sodium 

Chloride) ; Sugar Substitutes 211 

Beverages 211 

Tea 212 

Coffee 213 

Cocoa and Chocolate 216 

Mineral Waters 218 

Alcoholic Beverages 223 

Wines; Malt Liquors 226 

Malt Extracts 227 

Distilled Liquors 228 



PART III. 
FEEDING IN INFANCY AND CHILDHOOD. 

• CHAPTER XV. 

Breast Feeding — Feeding Normal and Abnormal Children. 

Woman's Milk 229 

Colostrum 229 

General Characteristics of Woman's Milk 230 

Quantity 230 

Composition 231 

Fat; Lactose 231 

Protein; Salts; Iron; Phosphorus; Salts of Woman's and Cow's Milk 232 
Bacteria; Drugs; Nervous Impressions; Pregnancy; Transmission 

of Immunity; Diet 233 

Breast Feeding 234 

Contra-indications for Breast Feeding 234 

Intervals of Nursing; Length of each Nursing 235 

Mother's Diet and Exercise 236 

Vomiting 237 

Gas and Colic; Al^normal Stools 238 

Mixed Feeding 238 

Weaning . 239 



CONTENTS ix 

CHAPTER XVI. 

Artificial Feeding. 

Food Requirements of the Artificially Fed Infant 241 

Energy 241 

Protein; Fat 242 

Carbohydrate 243 

Sugar 243 

Starch; Inorganic Salts 244 

Water 245 

Proprietary Foods 245 

Preparations Containing Cow's Milk; Preparations Containing Large 

Amounts of Maltose 245 

• Farinaceous Foods; Miscellaneous Foods . 246 

Artificial Feeding . _ 246 

Method of Preparing Formulae 247 

Increasing Formulae 248 

Cereal 249 

Higher Fat Mixtures 251 

Food Other than Milk 252 

Beef Juice and Broth; Beef Juice; Cereals 252 

Egg; Vegetables; Rice and Potato; Bread 253 

Abnormal Symptoms 254 

Vomiting; Gas; Colic 255 

Loose Stools; Diarrhea 256 

Constipation 257 

CHAPTER XVII. 

Feeding of the Premature Infant. Feeding after the First Year. 
Feeding during Acute Illness and in Nutritional Disturbances. 

Feeding of the Premature Infant 258 

Feeding during the Second Year 259 

Feeding after the Second Year 260 

Feeding during Acute Infections 261 

Infants 261 

Gavage 262 

Children Over One Year 262 

Gavage; Long Illness 262 

Pyloric Stenosis 262 

Cyclic Vomiting 264 

Feeding in Nutritional Disturbances 266 

Rickets 266 



PART IV. 

FEEDING IN DISEASE. 

CHAPTER XVIII. 

Diet in Diseases of the Circulatory Organs. 

Functional Cardiac Disturbances 271 

Diet in Organic Cardiac Disease 271 

Cardiac Decompensation 272 

The Karell Cure; Potter's Modification of the Karell Cure . . 273 



X CONTENTS 

Diet in Organic Cardiac Disease : 

Fatty Heart . . . . . . . .275 

Adolescent Heart and Cardiac Myasthenia following Infectious Disease 276 

Senile Heart 276 

Diet in Diseases of the Bloodvessels 277 

Arteriosclerosis 277 

Diet in Hypertension 278 

The Effect of Various Substances on Blood-pressure 278 

Aneurysm ^ 279 

Angina Pectoris; Tobacco in Relation to Cardiac Disease .... 279 



CHAPTER XIX. 

Diet in Diseases of the Lungs. 

Pneumonia 280 

Bronchitis 282 

Acute Bronchitis 282 

Chronic Bronchitis 283 

Emphysema 284 

Asthma 285 

Pleurisy with Effusion. Hydrothorax 286 

Empyema 287 

Tuberculosis, Pulmonary or General 288 

Prophylaxis for Children of Tuberculous Inheritance; Plan of Feeding 291 

Special Foods for the Tuberculous 292 

Milk; Eggs; Fats 292 

Complications 294 

General Rules for Feeding in Tuberculosis 295 



CHAPTER XX. 

Diet in Diseases of the Stomach. 

Indigestion 297 

Gastric Hyperacidity, Hyperchlorhydria .299 

The Reduction of Gastric Hyperacidity by Diet; Diet in Hyperacidity 300 

Gastric Hypersecretion 303 

Gastric Hypo-acidity and Achylia Gastrica 304 

Gastritis 306 

Acute Gastritis 306 

Chronic Gastritis 307 

Diet when Gastritis is Accompanied by Hypo-acidity or Achylia . . 309 

Peptic Ulcer (Gastric and Duodenal) 309 

Transgastric or Duodenal Feeding 322 

Diet Combined with Alkaline Treatment . 324 

Ambulatory Diet Cure for Peptic Ulcer 326 

Diet after Hemorrhage from Stomach or Duodenum 327 

Gastric Atony 328 

General Directions in Gastric Atony 329 

Organic Gastric Acidity 332 

Carcinoma of Stomach 333 

Gastric Dilatation 336 

Gastric Neuroses 337 

Secretory Neuroses; Neuroses of Sensation 338 

Motor Neuroses 339 

Gastric Test Meals . . 339 

Gastric Motor Meals 340 



CONTENTS xi 

CHAPTER XXI. 

Diet in Diseases of the Intestines. 

Acute Enteritis 342 

Chronic Enteritis 344 

Schmidt Test Diet 344 

Acute CoHtis or Acute Dysentery 346 

Chronic CoUtis 347 

Membranous Colitis, Mucous CoHc or Chronic Mucous CoHtis .... 348 

Ulceration of the Small or Large Intestine 349 

Intestinal Hemorrhage 350 

Diarrhea 350 

Dietary Regulations 352 

Foods to Avoid in Chronic Diarrhea; Foods Recommended in 

Diarrhea; Foods Allowed in Certain Cases . . . , . . 352 

Intestinal Neuroses 353 

Chronic Constipation 354 

Atonic Constipation ' 355 

Spastic Constipation 357 

Obstructive Constipation . 358 

The Use of Mineral Oil in Chronic Constipation 358 

Intestinal Atony 359 

Appendicitis 360 

Acute Appendicitis 360 

Ochsner's Treatment for Appendicitis 361 

Chronic or Larval Appendicitis 362 

Chronic Typhlitis or Perityphlitis . . , 363 

Intestinal Auto-intoxication 364 

Hemorrhoids 369 

Hirschprung's Disease 369 

CHAPTER XXII. 

Diet in Diseases of the Accessory Digestive Glands. 

Diseases of the Liver and Gall-bladder 371 

Dietetic Prophylaxis 372 

Acute Hepatic Congestion; Acute Catarrhal Jaundice or Gastro- 

duodenitis with Jaundice 373 

Chronic Hepatic Congestion; Portal Cirrhosis 374 

Biliary Cirrhosis; Fatty Liver; Acute Yellow Atrophy of Liver . . 375 

Amyloid Liver; Cholelithiasis 376 

Acute Cholecystitis and Colic 378 

Pancreatic 'Disease ..•••. 379 

Acute Pancreatitis; Chronic Pancreatitis 379 

CHAPTER XXIII. 

Diet in Diseases of the Skin. 

Psoriasis 383 

Eczema 385 

Acute Eczema; Chronic Eczema 386 

Eczema in Nurslings 387 

Acne Rosacea 388 

Acne Vulgaris 389 

Erythema 389 

Pruritus 390 

Dermatitis 391 

Dermatitis Herpetiformis; Exfoliative Dermatitis; Furunculosis; 

Comedones 391 

Hyperidrosis 39^ 



xii CONTENTS 

CHAPTER XXIV. 
Diet in Diseases of the Genito-urinary System. 

Nephritis 393 

Kidney Dietary Tests 395 

Water Excretion; Salt Excretion; Nitrogen Excretion .... 395 

Albuminuria 401 

Acute Nephritis 402 

Chronic Nephritis 405 

Dietetic Management of Chronic Nephritis 405 

Diets in Chronic Nephritis; Diets for Cases with Nitrogen Reten- 
tion (Chronic Uremia) 406 

Diet in Water Retention. Edema 407 

Diet in Salt Retention 408 

Pyelitis 412 

Cystitis 413 

Gonorrhea 413 

Nephrolithiasis 414 

Amyloid Kidney 414 

CHAPTER XXV. 

Diet in Diseases or Pathological States due to Disturbances of 
Normal Metabolism. 

Diabetes Insipidus 415 

Diabetes MeUitus 416 

The Relation of Protein Metabolism to Glycosuria 419 

The Nitrogen Balance in Diabetes 420 

Relation of Fat Metabolism to Glycosuria 421 

Hyperglycemia; Dietetic Treatment of Diabetes 422 

von Noorden Method 423 

Standard Strict Diet 423 

Standard Diet with Restricted Protein; Green Days . . . -425 
Oatmeal Days; General Diabetic Diet List; Foods Prohibited 

Except as Allowed in Accessory Diet 426 

Foster's System of Carbohydrate Units 428 

Sample Diet; Procedure in Medium Severe Cases; Severe Cases 

with Marked Ketonuria 429 

Potato Diet; Bread-and-butter Diet; Allen's Treatment of Dia- 
betic Mellitus 430 

Joslin's Resume of Allen's Treatment 436 

Menyhert's Theory 437 

Diabetic Special Receipts 438 

Diet for Diabetics with Gout; Diabetes in Elderly People or in the 

Young 442 

Diet for Obesity with Diabetes; Diet in Diabetes CompHcated by 

Nephritis 443 

Obesity 444 

Reduction Cures 448 

von Noorden's Cure . 448 

Banting's Cure 450 

Oertel's Cure 451 

Ebstein's Dietary; Schweninger's Dietary 452 

Germain-See Diet; Tibbie's Milk Cure; Salisbury Method; Tower- 
Smith's Modification of Salisbury Diet 453 

Galisch's Cure; FoHn-Denis Method of Reduction 454 

Exercise and Massage; Water in Obesity 456 

Gout 456 

Foods in Gout 460 

Carbohydrates; Salts; Alcohol 460 

Coffee, Tea and Cocoa 461 

Diet in Acute Gout or Podagra 461 



CONTENTS xiii 

Diet for Leanness or Fattening Cures 466 

Foods to be used in Fattening 467 

Carbohydrate , 468 

Fat; Alcohol 469 

Phosphaturia 470 

Physiological Phosphaturia; Nervous and Sexual Phosphaturia; 

Juvenile Type 471 

Phosphates and Calculi 472 

Diet Recommended for Calculi 472 

Oxaluria 473 

Diet in Oxaluria 473 

Mineral Springs 474 

Diet in Old Age 474 

Food Requirements of the Aged 475 

Foods Especially Desirable for the Aged 477 

Preparation of Food for the Aged 478 

Diet Routine in Old Age 479 

Osteomalacia 480 



CHAPTER XXVI. 

Diet in the Blood Diseases. 

The Anemias 482 

Treatment of Chlorosis ■ 483 

Rest 483 

Iron 484 

Diet in Chlorosis; Diets in Anemia. (Chlorosis) 485 

Secondary Anemia; Pernicious Anemia 487 

Posthemorrhagic Anemia 488 

Leukemia 489 

Hemophilia 489 

Purpura Hemorrhagica 490 



CHAPTER XXVII. 

Diet in Deficiency Diseases. 

Scurvy 491 

Diet in Scurvy 492 

Beriberi 493 

Pellagra 495 

Goldberger's Conclusions 495 



CHAPTER XXVIII. 
Diet in Diseases of the Nervous System. 

Organic Nervous Diseases 497 

Neuritis 497 

Epilepsy 498 

Insanity 499 

Apoplexy 500 

Functional Nervous Diseases 501 

Migraine or Periodic Headaches 501 

Chorea; Neurasthenia 503 

Weir Mitchell Diet and Treatment 505 

Digestive Neuroses; Insomnia 507 

Delirium Tremens 508 

Nervous Anorexia 509 



xiv CONTENTS 

CHAPTER XXIX. 

Diet in Acute and Chronic Infections. 

Fever 510 

Diet in Fever 513 

Carbohydrates; Protein 514 

Fats 515 

Beverages; Alcohol; Intervals of Feeding 516 

Typhus Fever 517 

Typhoid Fever 518 

Older Diets 518 

Bacteriological and Physiological Basis for More Liberal Diets . . 519 

Carbohydrates . . . 519 

Fats; Protein; Energy Requirement 521 

Results Obtained by Liberal Diet; Typhoid Diets 522 

Diet in Typhoid Complications 528 

Intestinal Hemorrhage; Perforation; Nausea and Vomiting . . 529 

Water; Paratyphoid Fever 530 

Malaria Fever 530 

Scarlet Fever 530 

Smallpox 530 

Cerebral or Cerebrospinal Meningitis 531 

Measles 532 

Influenza (Grippe) 532 

Acute Articular Rheumatism 533 

Diet in Acute Articular Rheumatism 533 

Subacute Rheumatism 534 

Chronic Rheumatism (Chronic Infectious Arthritis) 535 

Tetanus 535 

Yellow Fever 536 

Cholera 537 

Peritonitis 539 

Acute Peritonitis 539 

Chronic Peritonitis 540 

Chronic Infections 540 

Rheumatoid Arthritis. Arthritis Deformans 542 



CHAPTER XXX. 

Diet in Relation to Surgical Operations. 

Preoperative Diet 544 

General Directions for Cases of Laparotomy 544 

Diet Preparatory to Gastric Operations 545 

Postoperative Diet 546 

Postoperative Diet for the Digestive Tube; Diet after Tonsillectomy; 
Postoperative Gastric Diets; Diet after Gastro-enterostomy and 

Gastric Operations 546 

Finney's Diet List following the Operation for Gastro-enterostomy 550 

Intestinal Lesions 551 

Diet after Appendectomy 552 

Diet in Certain Complications following Abdominal Operations . . 552 

Vomiting from Acute Gastric Dilatation 553 

Prevention of Desiccation of the Tissues 553 

Dietary Measures in Postoperative Intestinal Distention . . . 554 
Diet after Gall-bladder Operations; Diet after Operation for Hemor- 
rhoids 555 

Feedmg after Intubation 556 



CONTENTS XV 



CHAPTER XXXI. 

Diet in Diseases of the Ductless Glands. 

Acromegaly 557 

Acute Thyroiditis 558 

Exophthalmic Goitre 558 

Diet to Meet Special Indications in Exophthalmic Goitre .... 560 

Diarrhea; Inanition 561 

Myxedema or Cretinism 561 

Addison's Disease 561 

CHAPTER XXXII. 
Diet in Miscellaneous Conditions. 

Artificial Methods of Feeding 563 

Rectal Feeding 563 

Protein 564 

Fats; Carbohydrates 566 

Precautions in Rectal Feeding 567 

Subcutaneous Feeding . 568 

Protein 568 

Fats; Carbohydrate 569 

Intravenous Feeding 570 

Diet in Pregnancy 571 

Nausea and Vomiting of Pregnancy 571 

Nephritis; Mild Auto-intoxication 572 

Contracted Pelvis or with Oversized Fetus 573 

Puerperium 573 

Foods Best Avoided; Diet List after Normal Confinement . . 574 

Sprue 575 

Dental Caries 576 

Diet Recommended for Speakers and Singers 578 

Diet Adapted to the Use of Brain Workers 578 

Diet for Athletes 579 

Sugar; Foods to Avoid 581 

Feeding of Unconscious Patients 582 

Food Poisoning 583 

Meat Poisoning; Fish Poisoning; Vegetable Poisoning; Poisoning by 

Canned Goods 584 

Special Dietary Cures 586 

The Vegetarian Diet 586 

Metabolism of Vegetarians; Vegetarian Diets 589 

Fletcherism r 590 

Fruit Cures 594 

Grape Cure 594 



CHAPTER XXXIII. 

Food Protection. 

Accessory Foods and Beverages 595 

Flies, Food and Disease 595 

Relation of Flies to Various Diseases 595 

Method of Prevention 595 

Beverages for the Sick 595 

Artificial Foods 59^ 

Olive Oil and its Dietary Usage 599 

Stenosis of Esophagus; Pyloric Stenosis; Gastric Dilatation; Chole- 
lithiasis; Gastric Hyperacidity 599, 



xvi CONTENTS 

CHAPTER XXXIV. 

Tables of Food Values and Weights and Measures. 

Average Chemical Composition of American Foods 60 1 

Table of Measures and Weights 609 

Apothecaries' Measures 609 

Apothecaries' Weights 609 

Approximate Measures 609 

Relative Value of Metric and Apothecaries' Measures 610 

Relative Value of Apothecaries' and Metric Measures 610 

Relative Value of Metric and Avoirdupois Weights 610 

Relative Value of Avoirdupois and Metric Weights 611 

Relative Value of Apothecaries' and Metric Weights 611 

Relative Value of Metric and Apothecaries' Weights 611 

Fisher's Table of One Hundred Calory Portions 612 

Table Showing the Nutritive Value of the Food Materials Calculated for 

the Quantities Commonly Required in Cooking Small Portions . . 618 



NUTRITION AND CLINICAL 
DIETETICS. 



INTRODUCTION. 

The term food may be applied to any material with the 
aid of which the body is able to maintain its characteristic 
functions: temperature regulation, the performance of work, 
the repair of wasted tissues, the production of new tissues, and 
those countless factors — connoted by digestion, absorption, 
circulation, etc. — involved in the preparation and transporta- 
tion of the ingested food to the seat of action of the prime 
factor of organization, the cell. 

In the various kinds of cells of a compHcated organism such 
as the human body, transformations are in progress which are 
qualitatively similar but which vary quantitatively accord- 
ing to their specific functions: thus we have the cells of the 
muscular system, whose chief function appears to be the per- 
formance of work and the liberation of energy for the main- 
tenance of body temperature, or the cells of the glandular 
organs which form substances to be secreted into or from the 
body, and of the nervous system which are concerned in the 
conveyance of impulses. Whatever may be the specialized 
function of any cell, it is imbued with the fundamental char- 
acteristic activities of all cells. The sum total of the activities 
of the individual cell or of the body as a whole are grouped 
under the term metabolism, by which we mean *'all chemical 
and physical changes which occur in living matter and which 
constitute the basis of the material phenomena of life." When 
such changes involve the transformation of simple into more 
complex substances, they are usually associated with an 
increase in the energy content of the compounds formed, 
and are designated as anabolic processes. Changes which are 
concerned with the disintegration of complex material with 
the formation of simpler products are designated as catabolic 
processes, and are ordinarily associated with the liberation of 
energy. By means of anabolic processes the products of diges- 



18 NUTRITION AND CLINICAL DIETETICS 

tion are built up into the active structural compounds of 
protoplasm, into secretions, or into complexes suitable for 
storage and future use. Such processes predominate in growth 
and in those organs or tissues associated with the elabora- 
tion of secretions. The catabolic processes involve a disruption 
of food-stufFs, of cell components, or of reserves, and the 
liberation of energy in the form of heat or mechanical work, 
the end-products of this activity being finally ehminated from 
the body. The cellular activities associated with muscular 
contraction and the^ regulation of body temperature are pre- 
eminently catabolic. In normal individual cells and in the 
body in general there is a nice balance between the anabolic 
and cataboUc processes. Any disturbance of this equilibrium 
may result in a pathological condition. Considerations of 
diet in disease are concerned almost entirely with altera:- 
tions in the balance between anabolic and catabolic activ- 
ities. 

Five important classes of food-stuffs are required to satisfy 
the needs of the body; the lack of any one of these would 
result in grave metabolic disturbances. They are: proteins, 
carbohydrates, Upins (fats and Hpoids), salts, and water. To 
this list of general classes may be added a sixth, the accessory 
food substances designated as vitamines. 

The collective expression, food, is appHed to naturally 
occurring combinations of the food-stuffs enumerated or to 
products from these. Since most foods are themselves con- 
glomerates of materials which have been associated with life, 
they contain in different proportions some of all the elements 
required by the human organism. Thus we have such foods 
as meat, eggs, etc., in which protein predominates, but which 
contain also fat, carbohydrates, water, and salts; or certain 
vegetable foods whose solid material is largely carbohydrate 
and salts, with a very small proportion of protein and fat. 

The functions of the food-stuffs are varied; proteins, carbo- 
hydrates, and lipins may be utilized by the body as a source 
of energy, the greater proportion of the energy requirement 
of the body is supplied, however, by the carbohydrates and 
lipins. Protein serves not only as a source of energy but as 
the source of amino-acids and radicles necessary for the forma- 
tion of body protein, secretions, etc. Salts and water, while 
not the source of energy, are essential factors in the constitu- 
tion and activity of all parts of the body. 

Proteins are, as we have just indicated, important as the chief 
source of nitrogen-containing substances necessary for life, 
being colloidal in nature and capable of combining with both 
acids and bases, and absorbing or entering into loose chemical 



INTRODUCTION 19 

combinations with salts and water, they share in a most varied 
activity in the body processes. 

In the cycle of life protein is synthetized in the vegetable 
kingdom, and this protein is utilized in the construction of 
animal protein. Animals appear to be unable to synthetize 
the greater number of amino-acids present in the protein 
molecule, particularly those containing cyclic nuclei. Plants, 
however, can form the amino-acids and conjugate them into 
protein. The animal organism is, then, dependent upon the 
plant for the basal units of its protein molecule. Before plant 
protein can be used it must be broken down into amino-acids 
or simple combinations of these, which are then built up into the 
type of protein characteristic of the particular tissue concerned. 
The object of feeding is to supply not only protein to the indi- 
vidual, but protein which will furnish the proper kinds and 
amounts of amino-acids. 

The second class of food-stufFs, carbohydrates, are used by 
the body as a source of energy in the performance of its many 
internal activities as well as of external work. They are, 
apparently, more readily accessible for such purposes than 
protein or fat; in all cases in which a sudden expenditure of 
energy is involved or in states in which the body is forced to 
draw upon its reserve supplies the depots of carbohydrate 
(glycogen) are the first to become depleted, after which the 
fats and proteins furnish the required nutritive materials. 
The absence of carbohydrates from the diet often results in 
pronounced metabolic disturbances, e. g., acidosis. 

Chemically, carbohydrates consist of carbon, hydrogen, and 
oxygen; the hydrogen and oxygen being often present in the 
proportions in which they occur in water. This last fact was 
responsible for the name. From the structural point of view 
we find carbohydrates to be oxidation products of polyhydric 
alcohols (ketone- or aldehyde-alcohols). Human food usually 
contains molecules consisting of chains of five or six carbon 
atoms or multiples of these. Starch, in which form the greater 
proportion of ingested carbohydrate food exists, is a polymer 
of the six carbon sugary — glucose. 

Lipins serve in a varied capacity in the body. The term 
designates a number of diflPerent types of substances which 
may be roughly divided into two groups: fats, which are 
combinations of fatty acids and glycerol or other alcohols, 
and lipoids^ which resemble the fats in certain properties but 
which differ in chemical constitution since they may or may 
not contain fatty acids. Of this latter group lecithin and cho- 
lesterol have been studied extensively; the others, such as 
complexes containing other lipoids, protein, carbohydrate, 



20 NUTRITION AND CLINICAL DIETETICS 

various organic and inorganic compounds, have received little 
attention and our knowledge of their functions is limited. 
The *'fat" present in food is a mixture of lipins. 

Fats are used almost exclusively in the production of energy 
or in the regulation of temperature. In temperature regula- 
tion it functions in a twofold manner: it yields energy in the 
form of heat as the result of oxidation, and it serves as an 
insulating medium in the form of deposited subcutaneous 
fat. Chemically considered, fats are combinations of carbon, 
hydrogen, and oxygen. As contrasted with the carbohydrates, 
fat molecules contain Httle oxygen, and consequently yield a 
greater amount of energy upon oxidation. A gram of fat will 
yield more than twice as much energy in the form of heat as 
will a gram of carbohydrate. The body appears to prefer 
carbohydrates, however, for the production of heat, at least 
for short intervals of time. It stores its energy-yielding 
material as fat; the quantity of carbohydrate stored in the 
body is comparatively small, not sufficient to last a man more 
than a day* or two even when some fat and protein are con- 
sumed at the same time, as in fasting. 

Water and salts are concerned not only in the structure of 
the cells but in the maintenance of normal physical and chem- 
ical relations between the parts of the cells — intracellular 
water and salts — and between the groups of cells which con- 
stitute the tissues and organs of the body — extracellular water 
and salts. Water gives to the blood its fluidity, and this 
enables it to permeate the cellular structures of the body, 
carrying with it the dissolved gases and substances used in 
the activities of the cell. Suspended in the water (colloidal 
solution) are proteins and organized bodies, the blood cells. 
The salts which are dissolved in the water assist not only in 
maintaining normal osmotic conditions between all parts of 
the body, but also a uniform reaction by combining with 
acids and bases and transporting them to the lungs and 
kidneys for excretion. 

Recent work has demonstrated the presence of other sub- 
stances in food which are essential for the normal functioning 
of the body. The absence of these materials results in patho- 
logical changes, and the ingestion of very small amounts is 
accompanied by rapid recovery. The name "vitamines" has 
been applied to these substances by Funk. There appear to 
be at least two more or less distinct types: material soluble in 
fat, designated by McCollum as "fat soluble A," and material 
soluble in water, designated as "water soluble B." We know 
little of the chemical nature of these substances. Their 
importance in the diet, however, is unquestioned. 



INTRODUCTION 21 

These, then, are the facts which underlie dietetics, and while 
they are indisputably exact, much of the success of feeding in 
disease still must rest on clinical experience; for given hard- 
and-fast scientific facts the personal equation always enters 
into the picture and it will always be true that certain indi- 
viduals will not react to food stimuli in the logical way, idio- 
syncrasy playing a not inconsiderable role. Since this is 
true in health, how much greater must be the variation in 
disease when one considers that all people differ in their 
habits, environment, age, activity of the glands of secretion, 
and susceptibility to certain food elements, etc. .^ 

It is undoubtedly true that in health some people eat too 
much, this being the larger error than that they eat too Uttle; 
on the other hand, in disease many if not most people eat too 
little and add an element of starvation to an organism already 
handicapped by functional disturbances, infections or what 
not. The crux of the matter lies in selecting a diet suited 
to the individual conditions under varying circumstances, not 
alone in quantity but in quality as well. Recent advances in 
our knowledge of the specific dynamic action of food-stuffs have 
made it easier to say what food should theoretically suit a 
certain set of circumstances and on this basis one can, to a 
certain extent, choose suitable feedings, provided the personal 
equation is not too insistent. 

In certain diseases the indications for diet are clear cut and 
are largely a matter of rule, adherence to which will usually 
bring about the result desired, e. g., in obesity, while in others 
there is no counting on the results, for the foods which suit 
conditions in one individual will fail to produce the desired 
result in another, so that while the principles remain the 
same the individual requirements may be quite different 
and opportunity is afforded for the practise of nice judgment. 
In such a disease as typhoid fever this is particularly true, 
and the best feeding results will be obtained by the medical 
attendant who gives the most attention to details and uses 
the best judgment in the selection of foods, both quantita- 
tively and qualitatively. In such conditions it is possible 
only to indicate the principles to be used in ordering foods, 
leaving the rest to the individual attendant's discretion. So 
it is throughout the entire range of disease — there must be a 
knowledge of the facts in the biochemistry of foods, combined 
with clinical experience and good judgment if one wishes the 
best results. 



PART I. 
FOODS AND NORMAL NUTRITION. 



CHAPTER I. 
DIGESTION, ABSORPTION AND EXCRETION. 

DIGESTION. 

Enzyme Action. — Food, when ingested, is, with but few 
exceptions, potential nourishment. Before it can be used in 
the body it must be reduced to simpler forms or Hberated 
from structures unavailable for absorption into the blood. 
Until a food is in a condition readily to pass through the walls 
of the alimentary tract, it is not available as a factor in metab- 
olism. Such transformations are accompHshed in the processes 
of digestion. As the result of these, solid masses of food are 
disintegrated, insoluble carbohydrate, fat, and protein com- 
plexes are transformed into compounds which are soluble or 
of such a size (ultramicroscopic) that they may readily tra- 
verse the walls of the alimentary tract and finally reach the 
blood and be carried to the various cellular structures of the 
body. This conversion of heterogenous food masses into a 
pabulum of comparatively simple and uniform consistency is 
accompHshed with the aid of .enzymes (ferments),^ whose 
activities are furthered by the mechanical movements of the 
alimentary tract. 

Enzyme action is catalytic in nature. In the presence of 
enzymes the rate of digestive activity increases. In the pres- 
ence of water or dilute solutions of alkalis or acids, the conver- 
sion of starch into maltose proceeds slowly. The addition of 
the salivary amylase, ptyaHn, to a starch mixture under suit- 
able conditions of alkalinity and temperature, increases the 
rate of the process; instead of requiring a period of days and 
weeks for the completion of the digestion of a given mass of 

^ While we will confine our discussion largely to the enzymes of the digestive 
tract, it must be remembered that enzymes are present in all tissues and fluids 
of the body. 



24 DIGESTION, ABSORPTION AND EXCRETION 



material, a few minutes or hours suffice. These changes are 
produced, furthermore, at the comparatively low temperature 
of the body. 

Enzyme action is specific; for each kind of substance to be 
changed a special enzyme is elaborated. If many intermediate 
products are formed, more than one enzyme may be required 
to reduce a food material to its simplest state. PtyaHn, the 
salivary amylase, can carry the digestion of starch only as 
far as the maltose stage. Another enzyme, maltase, is required 
for the cleavage of maltose in the formation of glucose. This 
enzyme is restricted in its action to maltose and glucose; it 
cannot change sucrose or lactose or any other carbohydrate. 
To complete the digestion of food, then, many different 
enzymes are necessary. 

Enzymes are classified according to the types of chemical 
reactions they affect. They are named by adding the suffix 
**ase" to the type of reaction, or to the substrate, the sub- 
stance upon which they act. Practically all the enzymes of 
the digestive tract are members of the group designated as 
hydrolases. Their function is to aid in the disintegration of 
complex food molecules, changes which involve cleavages of 
the molecule with the addition of the elements of water. The 
more important digestive enzymes will be discussed in con- 
nection with the digestive processes. 

The activities of any particular kind of enzyme are influ- 
enced by its environment. Such factors as {a) reaction, ih) 
temperature, \c) concentration of the enzyme, {d) concentration 
of the products of reaction, {e) presence of electrolytes — salts, 
alter the degree and intensity of enzymatic transformations. 

For each kind of enzyme there is a degree of acidity (excess 
of hydrogen ion) or alkahnity (excess of hydroxyl ion) at 
which it will produce its maximum effect. If this optimum 
concentration of hydrogen (or hydroxyl) ion is not reached or 
is exceeded, the action will be retarded because of the absence 
of sufficient ions to promote the activity of the enzyme or of 
an excess of ions which would result in an inhibition or destruc- 
tion of the enzyme. Most enzymes act best at a temperature 
between 35° and 45° C, approximately body temperature; 
they are destroyed at higher temperatures (70° to 100° C), 
and inhibited at lower temperatures. Although a small quan- 
tity of enzyme is capable of effecting the conversion of a large 
amount of food, with a greater concentration of enzyme the 
same result may be produced in a much shorter time, the 
increase in rate being in most cases approximately propor- 
tional to the concentration. An accumulation of the products 
of digestion tends to retard the speed with which the reaction 



DIGESTION 25 

proceeds.^ This is in accord with the usual course of chemical 
reactions in which the products are not removed. They pro- 
ceed in one direction until an equilibrium is reached between 
the reacting substances and the end-products, or until all of 
the reacting substances are consumed, when demonstrable 
reaction ceases; a change in the concentration of any of the 
factors results in a reaction which tends to restore the equi- 
librium, or cause it to go to completion. Certain enzymes 
have been shown to possess the power of reversibility such 
that they can cause a reaction to proceed in a direction oppo- 
site to that normally followed. Electrolyte facilitates or 
retards enzyme activity according to the kind and concentra- 
tion; small quantities of certain electrolytes are apparently 
essential. 

Some enzymes when secreted from the cell are in an inactive 
form which requires the action or presence of another sub- 
stance or enzyme before they become active. Such enzymes 
are called zymogens, or mother substances, and the activa- 
tion is caused by a zymo-exciter or kinase. For example, the 
activation of the zymogen, pepsinogen, is caused by the zymo- 
exciter hydrochloric acid and that of the zymogen, trypsinogen, 
by the kinase, enterokinase. 

Oral Digestion. — In the mouth the physical activities of 
the ahmentary tract predominate over the chemical. Here 
the food is finely divided and thoroughly mixed with the 
saUvary secretion. Three results are accomplished. By fine 
division the food is prepared for the subsequent action of the 
digestive juices. By the admixture of water and mucus dry 
and hard food masses are moistened and softened and swal- 
lowing is facilitated. The salivary amylase, ptyalin, is brought 
into intimate contact with the food and thus amylolytic 
digestion is- promoted. Food remains for so short a time in 
the mouth that relatively very little digestion occurs there. 
Thorough chewing, however, prepares the food for complete 
digestion in the stomach and intestines — including salivary 
digestion in the stomach. The function of saHva has been 
held by certain investigators to be primarily that of a lubri- 
cant in swallowing. The fact that the saUva of certain ani- 
mals, particularly carnivora, contains no amylase or other 
enzymes and that in aquatic mammals there is apparently no 
§alivary secretion of importance, are cited as proof of that 
inference. We shall see, however, that for man the digestive 
function of saliva is desirable although probably not essential. 

^ In the ordinary course of digestion, particularly in the intestines, the end- 
products are removed by absorption so that hydrolysis is facilitated rather than 
retarded. 



26 DIGESTION, ABSORPTION AND EXCRETION 

The quantity and quality of saliva secreted has been shown 
to vary with the nature of food ingested; coarse (dry), granu- 
lar, or acid food elicits the production of a thin, watery flow 
of saliva, while moist foods stimulate the flow of a more 
viscid secretion. The amount of saliva secreted is affected by 
the sight or smell of food, it is stimulated by appetizing food 
and inhibited by non-appetizing food. The total daily excre- 
tion is estimated at 1500 cubic centimeters, 50 ounces. 

The chemical constituents of saliva are principally water, 
mucin, inorganic salts — phosphates, chlorides, sulphates and 
carbonates and traces of thiocyanates, nitrites — and enzymes. 
Saliva is slightly alkaHne to almost neutral in reaction, hydro- 
gen-ion concentration 2-4 x io~^ approximately that of 
blood. The reaction fluctuates slightly with changes in the 
acid-base equiHbrium of the blood. A slightly acid saliva, 
2 X io~^ gram molecules of hydrogen ion, has been observed 
to flow from the salivary glands, particularly in association 
with acidosis. An acid, mixed saliva is obtained from the 
mouths of some individuals. In the latter case the acidity 
is often, the result of fermentation (bacterial) of food debris 
on and between the teeth. 

Salivary digestion is confined almost entirely to the trans- 
formation of starch and dextrins; cellulose is not attacked by 
it. Salivary amylase, or ptyaHn, is the principal enzyme in 
the saHva of man. Through its action insoluble or colloidal 
starch is converted into soluble and diffusible maltose and 
this, through the action of maltase present in the saliva and 
also in the intestine, is changed to glucose. The reaction best 
suited for the activity of salivary amylase is neutral to slightly 
acid, a hydrogen-ion concentration of 2 x io~^ has been 
found to be the optimum reaction; the presence of even a 
slight excess of acid inhibits its action. Protein combines 
with acid and the resulting compound is not sufl&ciently acid 
to prevent the action of saUvary amylase. 

Starch digestion continues for some time after the food has 
reached the stomach — half an hour or longer, according to the 
quantity and nature of the food ingested. This is particu- 
larly true in the case of soHd food because of the thorough 
mixing of food and saHva in the mouth and the collection of 
food in the fundus of the stomach. Furthermore, when protein 
is ingested with starch it combines with the acid of the stomach 
and for a time a reaction is maintained in the food mass which is 
suitable for the activity of salivary amylase. That amylolytic 
digestion in the stomach is desirable is indicated by the fact 
that protein food mixed with starch when subjected to the 
action of saliva has been shown to digest more rapidly with 



DIGESTION 27 

gastric juice than when not so mixed. This increased digest- 
ibility has been found to be due to physical changes in the 
starch. Boiled colloidal starch absorbs pepsin and thus 
inhibits its action. If, however, the starch be changed to 
its soluble form through the action of salivary amylase, the 
activity of pepsin is unaffected. Thus saHvary digestion of 
starch is an important aid to active gastric digestion. 

Gastric Digestion. — The stomach serves as a reservoir in 
which the food masses accumulate, are thoroughly mixed, 
acidified, partially digested, and passed on in small quantities 
to the intestine for further digestion and absorption. Milk is 
coagulated in the stomach at the begmning of its digestion. 
Very little absorption of food material takes place in the 
stomach. 

The resting empty stomach is practically collapsed. The 
fundus or cardiac portion of the stomach is in a sense a reser- 
voir which accommodates itself to the size of the entering 
material. As additional masses of food are passed into the 
stomach, the preexisting material is forced forward and to 
one side in such a way that the last portions of swallowed 
food are, in general, received within the mass already present 
in the stomach. Gastric juice is then secreted upon the sur- 
face of the soHd contents of the stomach and, in the fundus, 
digestion proceeds from the surface toward the center. The par- 
tially liquefied products are forced to the pyloric portion of the 
stomach by the tonic contractions of the stomach walls for 
acidification, further digestion and passage to the intestine. 
This arrangement and sequence of events permits of rather 
extensive salivary digestion in the center of the solid food 
masses in the stomach. The processes described above apply 
particularly to the more solid foods. Liquid or semisolid foods 
would not necessarily follow such a course. 

The walls of the fundus of the stomach are more or less in a 
continual state of contraction and force the food forward by 
steady pressure. The pyloric portion of the stomach, how- 
ever, is in active motion; contraction waves pass from the 
fundus toward the pylorus carrying some of the food mixture 
before them and against the closed pylorus. While the pylorus 
remains closed the material is not only carried forward by these 
waves but is also returned through the advancing rings of con- 
tracted muscle. 

Through the mixing of the food and the digestive action 
the heterogeneous food mass is converted into the liquid or 
finely divided semiliquid chyme. The addition of gastric 
juice increases the acidity of the mass. The pylorus is caused 
to open primarily by the acidity (true or hydrogen-ion con- 



28 DIGESTION, ABSORPTION AND EXCRETION 

centration) of the chyme forced against it. Hence when the 
acidity is sufficiently great, the pylorus opens and a portion 
of the acidified food is forced into the small intestine. The 
presence of acid in the intestine causes the pjdorus to close 
and remain so until the acid forced into it is neutralized and 
the chyme in the stomach is again acid enough to cause the 
pylorus to open. Recent work suggests that the discharge of 
the gastric contents is entirely controlled reflexly by the 
irritability or non-irritability of the gastric contents on the 
duodenal mucosa. Hard particles of food may temporarily 
prevent the opening of the p3dorus, and as we shall see later, 
certain material, particularly some of the liquid foods, may 
pass the pylorus without being acidified. Later in the pro- 
cess of digestion the pylorus permits even comparatively large 
masses of undigested food and indigestible material to pass 
into the intestine. 

For liquids the processes just described do not always occur. 
When water is taken, even on a full stomach, it passes through 
mto the intestines in a comparatively short time and without 
becoming acid in reaction. Examination of men and animals 
with the radiograph, and studies of the structure of the 
stomach and of the arrangement of its contents, have shown 
that water, in passing through the stomach, follows the lesser 
curvature of the stomach. Raw white of egg also passes 
through the stomach without becoming acidified. 

Milk is usually coagulated as soon as it enters the stomach; 
it has been shown, however, that during the early days of 
infancy, milk may pass directly into the intestine without 
becoming acidified or coagulated. Experiments with semi- 
solid foods and with milk have shown that when such foods do 
not pass directly into the intestines, the greater portion of the 
water and dissolved matter pass on and the more solid 
foods remain behind for digestion. Thus two portions of 
food containing the same amount of solid material, but one 
having a greater proportion of water than the other, will 
require practically the same time for digestion and passage 
out of the stomach. 

Aside from effecting mechanical mixture, the gastric pro- 
cesses are essentially proteolytic in effect. A milk-coagulating 
enzyme, rennin, and a lipase are also present, both of which 
are important under special conditions — rennin when milk is 
taken and Hpase when finely divided, emulsified, fats are 
ingested. Carbohydrates are undoubtedly hydrolyzed by 
hydrochloric acid, the extent depending upon the concentra- 
tion of the acid and the time it has to act. Such action is, 
however, under ordinary conditions, very slight. An exces- 



DIGESTION 29 

sive concentration of acid in the stomach, whether it be 
unneutraHzed appetite juice or ingested acid is usually accom- 
panied by a regurgitation of material from the duodenum. 
This regurgitated material tends, by neutralization, to reduce 
the acidity of the gastric contents. It has been suggested 
that such regurgitation is a normal mechanism by means of 
which the reaction of the gastric contents is maintained at the 
optimum reaction for the activity of the gastric enzymes. In 
the regurgitated material are the enzymes of the pancreatic 
and intestinal juices and also bile. The extent of the activity 
of these substances in gastric digestion is not known. The 
most important chemical factors in gastric digestion are, 
then, the enzymes — pepsin, rennin, and Upase — and hydro- 
chloric acid. The salts present are important aids to digestive 
activity. 

Pepsin (gastic protease) is secreted as pepsinogen from all 
parts of the gastric mucosa. The hydrochloric acid in gastric 
juice changes pepsinogen into pepsin and produces an acidity 
favorable for the accelerating action of pepsin. Hydrochloric 
acid is secreted chiefly in the fundus of the stomach; its con- 
centration when freshly secreted is from 0.4 to 0.5 per cent. 
The optimum acidity for peptic action is about 0.2 to 0.5 per 
cent, of hydrochloric acid or in terms of hydrogen-ion concen- 
tration, between i x io~^ to 4 x io~^ gram molecules of hydro- 
gen ion. The acidity of the gastric contents varies during 
the course of digestion, normally increasing gradually to a 
maximum and then decreasing somewhat. Fluctuations occur 
in the acidity with variations in the relative amount of asso- 
ciated substances, particularly proteins, that combine with 
acid. 

Through the action of hydrochloric acid and pepsin some 
solid protein materials are first swollen. This swollen pro- 
tein, together with the remaining protein material, is then 
broken down into simpler protein complexes, the proteoses 
and peptones. If the action be sufficiently prolonged arti- 
ficially, pepsin may hydrolyze protein to the simplest protein 
products, amino-acids, but in the body in the time during 
which protein ordinarily remains in the stomach, digestion 
proceeds to the proteose and peptone stages. Pepsin facili- 
tates the digestion of all proteins with the exception of kera- 
tin. While peptic digestion may not be complete in the 
chemical sense, it prepares the protein material for further 
digestion in the intestine. This is particularly true of collagen 
in connective tissue which permeates all animal parts. Colla- 
gen is swollen and partially hydrated in the stomach, an essen- 
tial process for its subsequent digestion by the proteolytic 



30 DIGESTION, ABSORPTION AND EXCRETION 

enzyme of the pancreatic juice, trypsin. As the result of peptic 
digestion, then, solid protein masses of food are disintegrated 
into smaller particles, and "peptonized," wholly or in part, 
forming a thin soupy mass which is readily passed on to the 
intestines. 

Fatty material is warmed by the stomach and, with the 
exception of the very soHd fats, melted, the connective mem- 
branes of the fatty tissue are digested and the fat liberated, 
and thus it is prepared for digestion in the intestines. Finely 
emulsified fats, e. g., cream, egg yolk, etc., are acted upon by 
gastric Hpase and hydrolyzed into fatty acids and glycerol; 
such action is, however, of little practical importance. 

Since salivary digestion is stopped by the presence of "free'* 
hydrochloric acid, carbohydrate digestion ceases as soon as 
the stomach contents become distinctly acid. 

The caseinogen of milk is transformed by rennin into insol- 
uble casein, which forms a clot. In the formation of the clot 
fat and other substances present in milk are entangled and 
held in the stomach with the casein. It has been shown that 
the watery portion of milk, whey, passes on quite rapidly into 
the intestines and that the solids (casein clot) are retained for 
digestion. This coagulative process permits the ingestion of a 
highly nutritious liquid without burdening the intestine with 
large quantities of complex undigested protein material. For 
a further discussion of rennin, see Milk, p. 130. 

Appetite is an important factor in digestion; that this is 
true is particularly evident in the case of gastric secretion and 
digestion, and the subsequent digestive processes. Gastric 
juice is secreted under the influence of two particular types of 
stimuli, psychical and chemical. The sight, thought, smell, 
or taste of food, or familiar sounds associated with food or its 
preparation will produce a flow of gastric juice. ^ This juice 
is highly acid in character and has a strong digestive power. 
It is designated "appetite juice" and is the result of nervous 
stimulation of the gastric glands. Such a flow of gastric 
juice is important. When it does not occur, as in experimental 
animals after food is placed directly in the stomach without 
the knowledge of the animal, only the secondary flow of juice 
resulting from chemical stimulation appears. The composition 
of "appetite juice" has been shown by Povlov to be approx- 
imately the same in quality regardless of the nature of the diet 
ingested; it varies in amount according to the extent and 
nature of the appetite stimulus. 

^ Similar and readily recognizable phenomena occur in the secretion of saliva; 
tlie "mouth waters" at the thought, sight, or smell of appetizing food, while 
unpalatable food does not have this effect. 



DIGESTION 31 

Secretion of gastric juice under the influence of chemical 
stimulation is varied: bread produces a copious flow of juice 
with a greater digestive capacity than meat; fats and alkalis 
in low concentration inhibit the flow of gastric juice; alkali 
in higher concentration may cause an increased flow of gastric 
juice. The apparent specific eflFects of foods are probably 
the result of variation in the degree of stimulation result- 
ing from the extractives and digestive products contained in 
the food or produced by digestion. This stimulation is prob- 
ably excited through Hberation of a gastric hormone. The 
importance of a secretion of appetite juice is, then, evident, 
for, in the case of food substances, which are not in them- 
selves "chemical" stimulants, products of digestion obtained 
under the influence of the psychical stimulation become the 
chemical stimulants of the gastric secretion which carries on 
the digestive process after that induced by nervous stimulation 
has ceased. 

Appetite has a secondary eff^ect upon the flow of pancreatic 
juice, for this is in a large measure related to the flow of gas- 
tric juice. Acid from the gastric mixture in the duodenum 
produces the hormone, or "chemical messenger" called secre- 
tin from an inactive mother substance: prosecretin. ^ Secre- 
tin is carried in the blood and lymph to the pancreas and 
intestinal glands where it stimulates the flow of the pancre- 
atic and intestinal juices, and to the liver where it stimulates 
a flow of bile. The flow of pancreatic juice is also affected 
by nervous stimuli. The indirect eff^ect of lack of appetite is 
a slowing of all digestive processes. A good appetite becomes, 
then, a most important factor in digestion. After suitable 
preparation food is more readily digested. 

The appetite is stimulated or depressed by the manner in 
which food is prepared, the way in which it is served and by 
the mental state of the individual concerned. Food properly 
cooked, well seasoned and attractively served tends to stim- 
ulate the appetite, whereas undercooked or overcooked food 
served in a careless manner does not stimulate the appetite 
and may even create a disHke for the food. The determination 
of what constitutes a well-cooked and attractively served meal 
rests to a large degree with the taste and habits of the one 
who is to eat it. Food which is properly cooked for one per- 
son may be unfit to eat in the estimation of another. Like- 

^ A hormone is a specific chemical substance produced, under a definite stimulus, 
in one organ which passes in the circulating blood and lymph to another organ 
in which it excites a secretion or change characteristic of that organ. The 
quantity of secretion or action produced is related directly to the quantity of 
hormone formed; a distinction from enzymes. Hormones are comparatively 
simple chemical substances, diffusible, heat stable, and readily oxidized. 



32 DIGESTION, ABSORPTION AND EXCRETION 

wise, attractive service is purely a relative term. An illus- 
tration of the varied tastes of individuals and even peoples 
is evident from a consideration of the diets of different 
countries and even in the same country. The mental state of 
the individual as affected b}^ pleasure, worry, excitement, pain 
or disappointment, also tends either to stimulate or depress 
the appetite. Appetite is not, however, an absolute necessity 
for complete and ready digestion of food, for it has been shown 
that food which was actually distasteful to the person eating 
it was just as completely digested and utiHzed as food which 
was eaten with a relish. 

Intestinal Digestion. — ^The digestion of food which has been 
started in the mouth and stomach is completed in the small 
intestine. The pancreatic and intestinal juices contain 
enzymes which accelerate the transformation of all three of 
the principal food-stuffs into soluble and diffusible products. 
The action of these enzymes is faciHtated by bile. 

Carbohydrates are changed into monosaccharides. Starch 
is hydrolyzed into maltose by the pancreatic amylase or amy- 
lopsin, and into glucose by the enzyme maltase. The sugars, 
maltose, sucrose and lactose, are broken down into glucose, 
fructose and glucose, and galactose and glucose respectively 
by maltase, sucrase and lactase. Unaltered protein with 
the exception of unhydrated collagen and keratin, and the 
products of peptic digestion are transformed into amino-acids 
by the trypsin present in the pancreatic juice and erepsin 
contained in the intestinal juice. 

Erepsin, the protease of the intestinal juice, secreted from 
glands in the intestinal mucosa, acts chiefly upon peptone and 
peptides, transforming them into amino-acids, thus complet- 
ing the digestion of protein which has been started by pepsin 
and trypsin. Erepsin does not digest natural complex pro- 
teins, with the exception of caseinogen, histones and prota- 
mines. Enterokinase, another intestinal enzyme, is an acti- 
vating enzyme which is capable of changing trypsinogen into 
trypsin. 

Nucleoproteins are only partially digested by pepsin and 
trypsin; their digestion is completed by special enzymes con- 
tained in the intestinal juice and in the walls of the intestines. 
Fats are emulsified in the intestines in the presence of soaps 
and hydrolyzed into fatty acids and glycerol by the pan- 
creatic lipase, steapsin. Bile also aids in the digestion of fat 
by increasing the solubility of the soaps and fatty acids; and 
by accelerating the action of the lipase. Bile contains no 
enzymes of importance. 

The most favorable condition for intestinal digestion is in 



ABSORPTION 33 

a neutral to slightly alkaline medium. The pancreatic juice 
is alkaline in reaction equivalent to approximately 0.5 per 
cent. Na2C03. It has a hydrogen-ion concentration of about 
2 X io~^ gram molecules per liter. 

The structure and movements of the intestines facilitate 
digestion and absorption but do not enable them to hold large 
quantities of food. Small quantities of chyme are received 
from the stomach as often as conditions in the stomach and 
intestines are suitable for its transferance; in general, when 
the acidity is sufficiently great to open the pylorus or when 
the acid chyme passed into the intestine becomes practically 
neutral. The reciprocal action between the two organs pre- 
vents overloading of the intestines with large quantities of 
acid material. 

The movements of the intestines have been described by 
Cannon after examination, with Rontgen rays, of the intes- 
tines of a cat fed with food mixed with bismuth subnitrate. 
He found that food masses passed from the stomach were 
collected together in the duodenum, mixed with pancreatic 
and intestinal juices and bile, and moved along the intestines 
in a continuous column. After the food mass had been car- 
ried for a short distance, the forward movement stopped and 
the solid column was broken up into short segments by a 
number of constrictions in the intestinal wall. These seg- 
ments were again divided, the halves of two adjacent seg- 
ments forming a new one. In this way the food masses were 
repeatedly divided without a forward movement of the total 
mass. After a time the material was moved along as a con- 
tinuous column, as before, to another portion of the intestine 
where segmentation again took place. By this means the 
intestinal juices are thoroughly mixed with the chyme, the 
enzymes have the maximum opportunity to act, and the food 
is brought into intimate contact with the walls of the intes- 
tines, thus facilitating digestion and absorption. 



ABSORPTION. 

Absorption of the products of digestion takes place largely 
in the intestines. The mucous membrane of the mouth 
exhibits absorptive powers, but the short time food remains 
in the mouth precludes any extensive absorption. In the 
stomach soluble food and the products of digestion are undoubt- 
edly absorbed to a certain extent, but again absorption is so 
slight as compared with intestinal absorption as to have no 
practical value. A considerable degree of gastric absorption 
3 



34 DIGESTION, ABSORPTION AND EXCRETION 

has been demonstrated, however, for water, salts, and alcohol. 
Absorption is stimulated by condiments. 

The maximum absorption of digestive products takes place 
in the small intestine: in the duodenum and the jejunum. 
Normally the absorption of food products in the small intes- 
tine is fairly complete and consequently in the large intestine 
there is relatively little absorption; and this is limited chiefly 
to water. Under certain conditions, as in rectal feeding, the 
large intestine appears to be capable of a considerable ab- 
sorption of food products. 

Attempts to correlate intestinal absorption with the known 
laws of diffusion and osmosis have failed to account entirely 
for the apparently selective absorptive powers of the mucous 
membranes. Since a dead membrane does follow these laws 
it has been suggested that certain "vital" forces are concerned. 
When we are fully conversant with the physico-chemic 
structures of the cell, it may be found that these apparently 
*' vital" phenomena are due to special adaptations of simple 
laws of solutions and diflPusion modified by the colloidal state 
of the substances present. 

The manner and form of absorption of protein or its prod- 
ucts are subjects of considerable controversy. Protein may 
be broken down in the processes of digestion into amino-acids 
and simple complexes of these, polypeptides. It was formerly 
supposed that protein material was absorbed either unchanged 
or as proteoses or peptone, and converted into blood protein 
or destroyed. This view was based largely upon the fact that 
it was impossible to detect the presence of amino-acids in 
digestive mixtures or in the blood. Refinement of the methods 
of analysis and more careful investigation have shown conclu- 
sively, however, that digestion of protein proceeds beyond the 
peptone stage and that protein is probably transformed 
almost entirely into amino-acids. This is in many wa3^s the 
more logical conclusion, since there are a number of cell and 
tissue proteins which contain different proportions of amino- 
acids than do the food proteins, and these are undoubtedly 
arranged after their absorption in a different manner in the 
various protein molecules in the cells and tissues. The absorp- 
tion of amino-acids and their simple complexes through the intes- 
tinal wall is more readily understood than that of colloidal 
protein structures, because the amino-acids are diffusible. 

Two views with regard to the way in which these simple 
products of protein hydrolysis are carried in the blood have 
received the most consideration: {a) that the amino-acids in 
their passage through the intestinal wall are resynthetized 
into protein material, principall}' serum albumin or serum 



ABSORPTION ' 35 

globulin, and are carried in this form by the blood to the cells 
for use in the processes of repair and growth or deaminized; 
(b) that the absorbed amino-acids are carried by the blood to 
the various cells in the body and used directly by the cells or 
destroyed either there or in the liver. The first conception 
is probably incorrect; it was based, in part, upon the fact 
that the products of protein digestion had not been found in 
the portal blood, and on the presence of large quantities of 
ammonia in blood coming from the region of the intestines. 
According to this theory at least a partial disintegration of 
the nutrient serum proteins into simpler forms was necessary 
before they could be of use in the structure of the qualita- 
tively different muscle and organ proteins. The excess of 
simpler forms, e. ^., amino-acids, remaining after the forma- 
tion of such more or less specific protein structures from the 
heterogeneous mass of structural forms presented were sup- 
posed to be deaminized in the intestinal wall or possibly in 
the blood. The carbon moiety, or mass of amino-acid material 
minus the amino radicle, was either oxidized as are the fats 
and carbohydrates, or synthetized to carbohydrates or pos- 
sibly fats. The nitrogen appeared as ammonium salts which 
were transformed by the liver into urea. 

The second theory is based upon recent investigations 
which have demonstrated quite conclusively that consider- 
able quantities of amino-acids are present in the blood of 
the portal vein and in the blood and tissues in general, and 
that the ammonia of the portal blood is not chiefly the result 
of deaminization in the small intestine but originates in the 
large intestine as the result of putrefactive processes. In the 
light of these investigations opinion with respect to the fate 
of the absorbed amino-acids and simple peptides has changed. 
Instead of being either synthetized into protein material dur- 
ing their passage through the intestinal wall or destroyed, a 
part, if not all, of the amino-acids are now believed to be 
absorbed into the blood stream without change. These simple 
digestive products are carried in the blood and lymph and 
taken up by the tissues for use in the general processes of 
repair and growth. The excess is deaminized, the amino 
radicle is transformed into urea, chiefly in the liver, partially 
in the muscles, while the carbon moiety is oxidized or used in 
the formation of carbohydrates or fat. 

Carbohydrates are normally absorbed as simple sugars, 
monosaccharides. Of these glucose predominates, since it is 
the end-product of the digestion of starch and maltose, and 
constitutes half of the yield from the molecule of sucrose and 
lactose. Fructose and galactose are converted either in the 



36 DIGESTION, ABSORPTION AND EXCRETION 

intestinal wall or in the liver into glucose, the carbohydrate 
characteristic of the body. These carbohydrates pass in the 
portal blood stream to the liver. This organ acts as a store- 
house and regulator of the supply of carbohydrate used in the 
body. The normal glucose content of the blood is approx- 
imately O.I per cent. The blood from the intestines during 
digestion, however, contains more than this amount. Under 
ordinary circumstances the liver removes this excess of glu- 
cose and transforms and stores it as glycogen. When the 
glucose content of the blood entering the liver falls below the 
normal amount, it receives sufficient glucose to keep this 
value constant. 

When readily absorbable carboh3^drates, such as sucrose, 
maltose, or lactose, are ingested in excess, they may be absorbed 
unchanged. But the blood apparently does not contain an 
enzyme capable of hydrolyzing or utilizing sucrose or lactose, 
for they are treated as foreign substances in the blood and 
are removed by the kidneys. Maltose, however, may be 
utilized by the tissues to a certain extent; excess quantities 
are excreted. When glucose appears in the blood in amounts 
greater than the normal or which exceed the threshold value 
of the kidney it appears in the urine. Such conditions exist 
in certain diseases such as diabetes and may also result from 
the rapid absorption of glucose from the intestines in quan- 
tities so great that the liver cannot take care of it. 

The appearance of sugars in the urine following too rapid 
absorption from the intestine is called "alimentary glyco- 
suria." The quantity of any sugar which can be ingested 
without causing alimentary glycosuria is termed the assimi- 
lation limit, and is more or less specific for each sugar. Tay- 
lor holds that there is apparently no limit, beyond the capac- 
ity of the individual to retain it, to the quantity of glucose 
which may be ingested and absorbed. Some of his subjects 
took as much as 500 grams of glucose at one time without 
eliminating sugar in the urine; the Hmit of others was lower 
than this. Since starch requires a longer time for digestion 
the absorption of the resultant glucose extends over a longer 
period of time. With such a gradual absorption glucose does 
not normally appear in the blood in concentrations which will 
result in an alimentary glycosuria. 

Glucose is used in the body, particularly in the muscles, 
for the production of energy. One of the intermediate prod- 
ucts appears to be lactic acid, which, upon further oxidation, 
gives carbon dioxide and water, which are excreted. Carbo- 
hydrates ingested in amounts more than sufficient to main- 
tain the stores of glycogen in the liver and muscles and for the 



ABSORPTION 37 

ordinary oxidative processes may be transformed into fat. 
Careful experiments have been conducted to prove this, for 
in spite of the general evidence obtained from feeding herbiv- 
orous animals, the formation of fat from carbohydrates has 
been questioned. By determining that a greater amount of 
fat was deposited in the body or excreted in milk than was 
contained in the food fed or could have been formed from 
the protein, it has been demonstrated quite conclusively that 
carbohydrates are used by the body in the formation of fat; 
careful respiration experiments have also shown this. 

Ingested fat is transformed in the intestines into fatty acids, 
soaps, and glycerol and absorbed in these forms. In their 
passage through the intestinal mucosa these products are 
resynthetized into neutral fats. Instead of passing directly 
into the blood through the capillaries of the intestines, as do 
the carbohydrates and the greater part of the protein diges- 
tion products, fat is taken up by the lymph ducts and poured 
into the blood stream with the thoracic lymph. It has been 
shown that fat-Hke substances such as petroleum hydro- 
carbon and esters saponified with difficulty (not fat) are not 
absorbed from the intestines. The use of petroleum oil to 
reheve constipation depends upon this fact. 

Studies of fat absorption have shown that fat which appears 
in the blood, or which is deposited in the tissues, or which is 
excreted in milk, may retain certain of the characteristics of 
the food fat, such as the iodine number, etc. Fats are, how- 
ever, changed in the process of absorption for, following the 
ingestion of a food fat with a high melting-point the blood 
fat shows a lowered melting point while the reverse is true 
when fat with a low melting-point is ingested. 

The fat content of the blood increases during feeding, for 
the absorbed fat is poured into the blood stream above the 
liver. Studies of the fat content of the blood have shown 
that fat begins to be absorbed about two hours after ingestion 
and reaches a maximum of absorption in about six hours. 
Bloor has suggested that lecithin takes part in fat absorption 
and that it is the first stage through which fat passes in the 
processes of utilization. In dogs, and by analogy probably 
in man, the fat content of the blood is fairly constant, except 
at times of active absorption from the intestines, showing a 
regulation somewhat similar to that observed in the case of 
glucose. When large quantities of fat are being utilized, as 
in fasting or diabetes, there is often an increase in the blood 
fat. 



38 DIGESTION, ABSORPTION AND EXCRETION 

BACTERIAL ACTION AND FECES. 

Intestinal Bacteria. — Food is disintegrated through the 
action of bacteria as well as by the digestive processes which 
take place in the intestines as the result of the action of the 
digestive enzymes. Such digestion takes place normally and 
to a greater extent in the large intestine in the case of poor 
digestion and absorption in the small intestine. The bacteria 
active in the intestines may be grouped into two general 
classes: first, those which act primarily upon carbohydrate 
material and which produce alcohol and organic acids, such 
as lactic, acetic, butyric, benzoic, succinic, valerianic acids, 
accompanied by the evolution of carbon dioxide and methane. 
These are ordinarily classed as fermentative bacteria. Their 
action is not restricted to soluble carbohydrates; certain 
kinds are capable of digestmg cellulose. Bacteria which act 
upon cellulose are of practical importance to the herbivora 
which obtain a portion of their carbohydrate material through 
such action. Fermentative bacteria require in general a 
neutral to slight^ acid medium for their growth and activities. 

To the second class of bacteria of importance in the diges- 
tive tract belong those whose action is confined primarily to 
protein material, often classed as putrefactive bacteria, and 
which are chiefly anaerobic. 

The relative number of bacteria excreted per day in the 
feces has been placed at between 33 to 128 x 10^^. A large 
proportion of these are dead. One estimate has placed the 
relative proportion of dead bacteria in feces at 99 per cent.; 
this value is difficult to determine because of the varying 
condition in the intestines. The actual weight of dry bac- 
teria excreted per day has been found to be between 5 to 8 
grams. 

Among the products of putrefaction are the proteoses, pep- 
tones, and amino-acids obtained in the usual digestive processes. 
In addition to these, however, are a number of products more 
or less characteristic of bacterial action, such as the nitrogen- 
ous substances of the aromatic series — indol and skatol, phenol, 
cresol, phenyl-propionic acid, certain of the amines, accom- 
panied often by the development of. gas; hydrogen sulphide, 
carbon dioxide, methane, hydrogen, and ammonia. Certain 
of these products are toxic, particularly those of the aromatic 
series and the amines. 

It has been demonstrated that indol, phenol, skatol, etc., 
are detoxified, conjugated, with sulphuric acid, hy the 
liver to form compounds of the type of indican (indoxyl 
potassium sulphate) in which form they are excreted in the 



BACTERIAL ACTION AND FECES 39 

urine. During or after excessive putrefaction these products 
may not be entirely conjugated when various abnormal 
effects, among them nervous disturbances, occur which are 
ordinarily included in the meaning of the term auto-intoxica- 
tion. The quantity of indican in the urine during a given 
period has been generally accepted as a good index of the 
extent of intestinal putrefaction. 

An alkahne reaction is particularly favorable for the growth 
of putrefactive bacteria. The large intestine is the only por- 
tion of the intestinal tract in which such a condition normally 
prevails. Some bacteria particularly of the B. coH type may 
be both fermetative and putrefactive in effect. They tend, 
however, to antagonize the putrefactive anaerobes. 

In the stomach the action of bacteria ingested with the 
food is retarded if not completely destroyed. The hydro- 
chloric acid of the gastric juice is sufficiently concentrated to 
destroy certain types of bacteria; only the active bacteria of 
other types are destroyed while the spores are resistant to its 
action. Bacterial action, then, in the normal stomach is prac- 
tically negative. It is quite probable that pathogenic bac- 
teria, which are ordinarily destroyed by the hydrochloric acid 
of the gastric juice may enter the intestine with undigested 
food particles and oil globules or in water that passes through 
the stomach without becoming acidified to any extent. In 
the presence of large quantities of protein, which combines 
with the hydrochloric acid of the gastric juice and tends to 
lower the acidity of the gastric contents or following the inges- 
tion of alkaline drinks or doses of alkaline salts, bacteria 
may develop or escape destruction. In certain abnormalities 
hyperchlorhydria, atony of the stomach, etc., or conditions in 
which the concentration of the hydrochloric acid is lowered 
through any cause, fermentative bacteria often develop, and 
produce organic acids, alcohol and carbon dioxide. The 
excessive ingestion of carbohydrate, particularly sucrose (cane- 
sugar) and glucose, often leads to such fermentation. Yeasts 
grow even in acid solutions. Their development in the stom- 
ach is accompanied by the production of organic acids, e. g., 
lactic and butyric acids, particularly following the ingestion 
of sugars, in cases in which there is a slow emptying of the 
stomach. 

The reaction of the small intestine is favorable for the 
growth of fermentative bacteria. This is true particularly in 
the lower parts of the small intestine, for the contents of the 
upper portion of the duodenum are slightly alkaline. Here 
the acid contents of the stomach are wholly or partly neu- 
tralized by the relatively large volumes of pancreatic and 



40 DIGESTION, ABSORPTION AND EXCRETION 

intestinal juices and the bile, which, while only slightly alka- 
line in reaction, are capable of neutralizing considerable acid. 
In the lower portions of the small intestine, particularly the 
jejunum and ileum, the intestinal contents are nearly neutral 
to slightly acid as the result of the partial neutralization of the 
intestinal and pancreatic secretions by the hydrochloric acid, 
and of the organic acids — produced during the digestion of 
fat and probably also by bacterial action. These portions of 
the intestine are, then, favorable to the growth of fermenta- 
tive bacteria. Examination of intestinal contents has demon- 
strated a pronounced growth of such bacteria. The effect of 
bacterial action in this region is not particularly harmful, for 
the products of fermentation are not, in general, toxic. The 
evolution of considerable quantities of carbon dioxide often 
leads to flatulence. Herter has suggested that the presence 
of an excess of fatty acids causes intestinal irritation, and 
diarrhea. 

Putrefaction and Feces. — Putrefactive processes predomi- 
nate over fermentative in the large intestine. The protein 
material which comes from the small intestine is here acted 
upon by the putrefactive bacteria of which B. coli, B. lactis 
aerogenesy Bad. zvelchi, B, hifidus and certain cocci predomi- 
nate. The character of the bacteria present depends to a 
certain extent upon the nature of the food ingested. In a fav- 
orable medium certain types of bacteria will grow rapidly and 
in so doing form products which inhibit the growth of other 
types. The predominance of B. hifidus in the intestinal tract 
of the infant has been explained as due, in part at least, to 
the continual presence of lactose in the diet and to the slight 
acid reaction of the feces, a condition which results from the 
activities of B. hifidus. Acidity of the feces is sufficient to 
inhibit the growth of practically all putrefactive bacteria. 
The gradual change in the diet of the infant, even a change 
from the breast milk with its relatively high lactose and low 
protein content to cow's milk with its lower lactose and higher 
protein content, tends to make B. hifidus disappear and other 
types, particularly B. coli, to predominate. A large propor- 
tion of the bacteria cultivable on artificial media present in 
adult feces are B. coli. This organism is not entirely dependent 
upon carbohydrate; it can grow either in a carbohydrate- 
protein medium or in one in which available carbohydrate is 
entirely absent. 

Material which is passed from the small into the large intes- 
tine through the ileocecal valve is of practically the same 
consistence as that ejected from the stomach into the small 
intestine; a semiliquid mass. This is true because the active 



BACTERIAL ACTION AND FECES 41 

absorptive processes of the small intestine, which remove both 
water and solids, are compensated by subsequent excretion of 
water through the intestinal walls. The total mass of the 
material is, however, greatly reduced. The large intestine in 
man is essentially a concentrating, absorptive, organ; its secre- 
tion, which is rich in mucus and alkaline in reaction, has not 
been shown to exert material digestive action. Digestion 
continues, however, as a result of the action of enzymes from 
the small intestine and other transformations result from the 
action of bacteria. The latter processes are of particular 
importance in certain of the lower animals in which the cecum 
is larger than in other animals. 

In the upper portion of the large intestine the semiliquid 
mass from the small intestine is concentrated; water in par- 
ticular is absorbed. This thickened mass is then passed to 
the transverse and descending portions of the colon, and fin- 
ally out of the body. Observations of the passage of food 
through the large intestine by means of the ;v-rays have lead 
to the conclusion that, in general, two hours are required for 
transit through each of the three parts of the colon, i. e., 
ascending, transverse, and descending. Sleep appears to 
retard, while the ingestion of meals accelerates the movement 
of material in the large intestine. 

The time required for the passage of food through the ali- 
mentary tract varies with the nature of the food ingested and 
with the condition of the individual. According to the obser- 
vations just noted the time is usually from eight to twelve 
hours. Under conditions of regular routine and uniform 
mixed diet, the residue from food ingested on a given day may 
be eliminated on the following morning. Even under such 
circumstances characteristic particles of food in a certain 
meal may appear in the feces days after the ingestion of that 
particular food. With the ingestion of a diet which is almost 
completely absorbed, or in fasting, defecation may take place 
only once in two or three days. On the, other hand, foods 
which irritate the intestinal mucosa pass out promptly. 

The material passed from the large intestine varies with 
the nature of the food ingested. It consists chiefly of undi- 
gested and unabsorbed food, bacteria and bacterial products, 
cast-off cells, the residues of intestinal secretions and salts. 
Fecal material is formed even in fasting, such feces consist 
entirely of the residue from intestinal secretions, cellular 
material, bacteria, and bacterial products. 

In the course of digestion relatively large quantities of secre- 
tions are poured into the alimentary tract and a considerable 
quantity of epithelial cells are mechanically removed. A large 



42 DIGESTION, ABSORPTION AND EXCRETION 

proportion of this material is reabsorbed, a certain quantity 
is, however, ehminated in the feces. 

When considering the absorption of foods from the intes- 
tine, it is necessary to make a distinction between the material 
remaining undigested and unabsorbed and that secreted into 
the intestines in the process of digestion, designated as "meta- 
bolic products." The quantity of such material eliminated has 
been studied particularly with regard to the utilization of 
nitrogenous foods in which case the ''metabolic nitrogen" is 
involved. A determination of the fecal nitrogen excreted in 
fasting would seem a most logical manner of estimating approx- 
imately the "metabolic nitrogen" in this relation. Studies of 
the influence of indigestible non-nitrogenous materials in their 
passage through the mtestine upon the excretion of nitrogen 
indicate an increase in the fecal nitrogen in their presence over 
that excreted in their absence. For a large mass of inert 
material, in addition to holding a certain amount of the secre- 
tion by absorption, tends to increase the rate of peristalsis. To 
determine the "metabolic nitrogen," then, it is essential that a 
mass of non-nitrogenous material^ be ingested which will yield 
a fecal residue of approximately the same size as that of the 
diet under consideration. Estimates of the metabolic nitrogen 
of man indicate the amount to be approximately i gram of 
nitrogen per day. Recent experiments in which agar agar was 
used as the inert material have placed this value at 0.5 gram 
of nitrogen per day. 

The degree of indigestibility of the food-stuffs affects the 
quantity of feces formed. Foods which contain a large pro- 
portion of indigestible material result in a greater fecal mass 
than those which are readily digested and absorbed. Foods 
rich in cellulose yield large watery stools containing consid- 
erable undigested protein and fat which have been protected 
from the action of the digestive enzymes by the indigestible 
cellulose. The relative composition of the feces from easily 
digestible and completely absorbed food is approximately the 
same irrespective of the nature of the diet. This has been 
demonstrated by feeding diets of meat and of rice alternately, 
in which it was found that the figures for percentage compo- 
sition of the undigested residues were quite similar, i. e., the 
quantity of nitrogen and fat excreted in the feces was 
roughly the same. In these cases the fecal material con- 
sisted largely of the metabolic products. An increase in the 
quantity of food does not result in an equivalent increase in 
the fecal output. An increase of 80 per cent, in the quantity 

^ Agar agar has been suggested for this purpose. 



EXCRETION 43 

of food ingested (bread) has been found to cause an increase 
of only 15 per cent, in the quantity of feces. With meat the 
effect is less — because of its greater digestibility. Milk has a 
different effect; an increase in the quantity of milk ingested 
results in a proportional increase in the fecal output, because 
of the unabsorbed inorganic constituents of the milk, calcium, 
and phosphorus, and, to a less extent, of the nitrogenous 
material. 

We conclude, then, that for easily digestible diets, such as 
meat, eggs, milk, rice, cheese, starches, etc., the fecal material 
consists essentially of the residues from the intestinal secre- 
tions, cellular material, inorganic salts, bacteria, and bacterial 
products. Diets containing relatively indigestible material, 
such as vegetables, or those which have not been properly 
digested because of insufficient mastication or deficient peris- 
talsis, will yield stools containing food residues and probably 
a greater quantity of non-reabsorbed metabolic products than 
easily and properly digested diets. 

The reaction of the feces is normally neutral to slightly 
alkaline to litmus. Feces from a highly nitrogenous diet 
exhibit an alkaline reaction due to the production of ammonia 
in the process of putrefaction. When fermentation predom- 
inates, the reaction of the stool will probably be slightly acid 
because of the presence of organic acids produced. 

The large intestine is capable of absorbing considerable 
nutriment when it is presented to it as in rectal feeding, par- 
ticularly the products of protein digestion, proteoses, pep- 
tones, amino-acids and the diffusible carbohydrates. This is 
of practical importance in the feeding of the sick, which will 
be discussed later. Cannon has observed the action of the 
large intestine after rectal injection of enemata. He studied 
the effect in cats, of large and small amounts of thin fluid 
masses, and of thick, mushy masses, and found that the food 
was largely absorbed in the upper part of the large intestine, 
to which it was carried by antiperistaltic waves. After 
abundant injections the food passed the ileocecal valve and 
into the small intestine. Nitrogen equilibrium has been main- 
tained for fifteen days in a boy with a stricture of the esoph- 
agus when fed, per rectum, with a mixture of protein (meat) 
digestion products obtained by digestion in vitro with trypsin 
and erepsin. 

EXCRETION. 

The excretion of- the products of general metabolic activity 
takes place through the lungs, kidneys, large intestine and 
skin. Of the products of carbon metabolism, carbon dioxide 



44 DIGESTION, ABSORPTION AND EXCRETION 

and water, the former is excreted almost entirely through the 
lungs; water is excreted through all excretory channels. The 
nitrogenous end-products of protein metabolism, salts, and, 
to a certain extent, the carbon end-products are excreted 
through the kidneys. The feces contain metaboHc end-prod- 
ucts that are excreted through the liver and the walls of the 
intestines, and in addition undigested food material and epi- 
thelial cells from the intestinal tract, bacteria and their prod- 
ucts. The extent to which excretion takes place, or may take 
place through the intestine is not well understood. Certain 
mineral salts, such as calcium, magnesium, together with the 
phosphate radical, iron, and salts of silicon, are excreted into 
the lumen of the intestine. Intestinal excretion of inorganic 
salts depends to a large extent upon the nature of the food 
ingested, i. e., whether or not it yields an excess of acidic or 
basic radicles as the result of metabolic processes. Because of 
the appearance of the salts of calcium, phosphate and iron in 
the feces it was formerly supposed that these salts taken in 
the inorganic form were absorbed with difficulty, and hence 
they must be supplied in organic combinations. It has been 
shown, however, that they are actively excreted through the 
bile and walls of the intestine. A larger proportion of calcium 
and magnesium appears in the urine following an acid diet 
than occurs from an alkaline diet. Certain substances are 
excreted through the bile — cholesterol, lecithin, and bile pig- 
ments. Salts of the heavy metals which are toxic when ingested 
appear largely in the bile, and subsequently in the feces. 

Epidermal excretion consists chiefly of water with small 
amounts of nitrogenous waste products, lipins, and salts. 

In the course of protein metabolism, the amino-acids, and 
possibly more complex molecules are absorbed from the 
intestinal tract, and are taken up in part by the tissues and 
synthetized into protein molecules. Amino-acids not used in 
the processes of synthesis are deaminized, and the resultant 
ammonia is converted into urea and excreted; a small proportion 
of the absorbed amino-acids may be stored for a time. Such 
processes take place throughout the body, but they occur to a 
greater extent in the liver and the intestines. The carbon- 
containing fragments of the molecules of amino-acids may 
be oxidized or synthetized into carbohydrate or fat. In the 
tissues protein molecules are broken down entirely or in part 
into amino-acids or simple complexes of these which meet a 
fate similar to those ingested. 

Among the constituents of food and tissues are nitrogenous 
compounds other than simple amino-acids, such as nucleo- 
proteins and products of their hydrolysis, purin and pyrim- 



EXCRETION 45 

idin bases, uric acid, creatine, creatinine, heterocyclic ring 
compounds, urea, and ammonium salts. Some of these are 
not available for body functions and are excreted unchanged; 
others may take part in cellular activities, although our knowl- 
edge on this point is not definite. 

Nitrogen is excreted chifly as urea, ammonia, uric acid, 
creatinine, creatine, and purine. The following table^ gives 
the composition of urine obtained after the ingestion of two 
types of diet: high and low protein content. 

Composition of Normal Urine Excreted following the Ingestion of 
A High Protein and a Low Protein Diet. 

Per cent. Per cent, 

of total of total 

High protein diet. nitrogen. Low protein diet, nitrogen. 



Volume of urine . . 1170 c.c 
Total nitrogen 
Urea nitrogen 
Ammonia nitrogen 
Uric acid nitrogen 
Creatinine nitrogen . 
Undetermined nitro- 
gen 0.85 " 4.9 0.27 " 7.3 



16.80 gm. 

14.70 " 87 

0.49 ;; 3 

0.18 " I 

0.58 " 3 



385 c.c. 
3 • 60 gm. 

5 2.20 " 61.7 

0.42 " I I. 3 

1 0.09 " 2.5 

6 0.60 " 17.2 



Per cent. Per cent. 

'of total of total 

SO3. SO3. 

Total SO3 . . . 3.64 " .. 0.76 " 

Inorganic SO 3 . 3.27 " 90.0 0.46 " 60.5 

Ethereal SO 3 . . . 0.19 " 5.2 o.io " 13.2 

Neutral SO3 . . . 0.18 " 4.8 0.20 " 26.2 

The greater proportion of the urinary nitrogen is excreted 
as urea. The daily excretion of urea is approximately 30 
grams, equivalent to about 80 to 90 per cent, of the total 
nitrogen in the urine. These values vary with the nature of 
the diet, its protein content, the activity and rate of metab- 
olism and the degree of retention of nitrogen-containing sub- 
stances. An excessive ingestion of protein or increased body 
activity is accompanied by an increased urea output, both 
absolute and relative; a decreased protein, ingestion or reten- 
tion of nitrogen is accompanied by a lowered urea excretion. 
Since urea represents a large proportion of the urinary nitro- 
gen determinations of this factor are sometimes taken as an 
indication of the extent and nature of protein metabolism. 

The amounts of urea and ammonia which appear in the 
urine are closely related. Urea is formed from ammonium 
carbonates and carbamates. Any factor which prevents the 
transformation of ammonia into urea, such as the formation 
of ammonium salts of highly dissociated acids or the produc- 
tion of excessive quantities of organic acids which are neu- 

iPolin: Am. Jour. Physiol., 1905, xiii, 118. 



4G DIGESTION, ABSORPTION AND EXCRETION 

tralized by ammonia, induce decreased urea excretion accom- 
panied by increased ammonia excretion. When there is an 
excess of acidic over basic radicles in the body, the acidity is 
reduced by two processes in particular: excretion of the acid 
radicle as a salt of a strong base and of the hydrogen in com- 
bination with a phosphate radicle, or excretion in combination 
with ammonia. Thus a diet whose ash yields an excess of 
acidic over basic radicles will be accompanied by a relatively 
high ammonia excretion. Or, the presence of an excessive 
quantity of organic acids in the body as the result of a failure 
to oxidize them is followed by an increased excretion of 
ammonia. 

Creatinine appears in the urine of normal adults in amounts 
comparatively constant from day to day — i or 2 grams — • 
but with slight fluctuations throughout the day. Diet has 
little effect upon the excretion of creatinine. According to 
Folin the excretion of creatinine is a measure of endogenous 
metabolism. It has been suggested that there is a relation 
between the mass and activity of the muscular system and 
the quantity of creatinine excreted in the urine. This rela- 
tionship may be expressed in terms of body weight; it varies 
with different individuals but is fairly constant for each. 
The normal value for the average person has been found to 
be from 7 to 1 1 milligrams of creatinine per kilogram body 
weight. 

Creatine, which is closely related to creatinine, appears in 
the urine of women at cyclic intervals of menstruation and 
following childbirth and is a normal constituent of the urine 
of children. It also appears during fasting and in diseases 
involving carbohydrate metabolism. There seems to be a 
certain relation between carbohydrate metabolism and the 
excretion of creatine such that in the absence of carbohydrates 
or in disturbed carbohydrate metabolism creatine appears in 
the urine. The ingestion of creatinine is followed by an 
increased creatinine elimination. Creatine, when ingested, is 
accompanied by an increased creatine excretion, but has 
little effect upon the excretion of creatinine. Our knowledge 
of the importance and significance of creatine and creatinine 
is very limited. 

Uric acid is, in man, an end-product of the metabolism of 
nucleins either of the food or of the tissues, or both'. It is 
derived chiefl}^ from the oxidation of purine bases. The aver- 
age excretion for man is about 0.6 gram per day; it vanes 
from 0.3 to 1.2 gram per day. The ingestion of purine- 
containing foods, or accelerated nuclear metabolism, is accom- 
panied by an increased uric acid excretion. Uric acid is 



DIGESTIBILITY OF FOOD 47 

practically insoluble in water; its solubility is decreased in 
acid solutions and increased in alkaline solutions. By vary- 
ing the nature of the diet, and consequently the reaction of 
the urine, it has been found that the quantity of uric acid 
which the urine is capable of dissolving (or holding in solu- 
tion) is increased by a diet yielding an alkaHne ash and 
decreased by one yielding an acid ash. 

DIGESTIBILITY OF FOOD. 

The food value to the body, of any particular food, depends 
upon the quantity of assimilable matter it yields as the result 
of digestion. The relative digestibility of foods is, then, an 
important factor in determining the diet from either a clinical 
or an economic point of view. In feeding the sick or delicate 
persons the ease, rapidity, and completeness with which the 
ingested food is digested, absorbed and assimilated, are essential 
factors. The economist is particularly concerned with the com- 
pleteness or extent of digestion, while the physician must 
know something of the ease with which food is digested and 
assimilated. These attributes of metabolic availability are 
subject to considerable variation. Digestion is influenced by 
many modifying factors; such as psychical influences which 
accelerate or inhibit the motor as well as the secretory activ- 
ities of the alimentary tract; the kind of food; the mode of 
preparation; the degree of comminution, including mastica- 
tion, and (considering individual food-stuff's) the nature of 
material with which it is associated. Psychical stimuli accom- 
panying contentment, pleasurable surroundings, well-served 
and appetizing food tend to facilitate digestion, while those 
which originate from fear, anger, worry, keen anticipation, 
and even high degree of happiness inhibit the activities of the 
alimentary tract and thus delay digestion; fortunately the 
unfavorable emotions are usually accompanied by a loss of 
appetite which prevents the ingestion of food. 

The quantitative measure of digestibility of a particular 
food-stuff is the ratio between the quantity absorbed and that 
ingested. The degree of absorption is determined by sub- 
tracting the amount of undigested food-stuff^ from that 
ingested. In estimating the quantity of undigested material 
in the feces, allowance must be made for the constituents 
which have been secreted or excreted into the intestine dur- 
ing digestion, such as those in the digestive juices, epithelial 
cells, fats, etc., and which, originating in the body, arise ulti- 
mately from food that has been absorbed. This form of 
excretion, so far as it is related to nitrogenous constituents, has 



48 DIGESTION, ABSORPTION AND EXCRETION 

been called *' metabolic nitrogen." Under abnormal condi- 
tions, such as excessive or retarded peristalsis the digest- 
ibility of food varies. With excessive peristalsis, the digestive 
juices do not have sufficient time to act, and there is a conse- 
quent lower utilization. Such a condition may be associated 
normally with a very bulky diet, such as with a predominantly 
vegetable regimen. 

Studies of the comparative digestibility of protein, fat, and 
carbohydrate of various types of foods, when ingested by man 
as a mixed diet, have been made b}^ Atwater. A summary of 
his results is as follows: 



Coefficients of Digestibility of Food-stuffs in Different Groups 
OF Food Materials. (Atwater.) 

Protein. Fat. Carbohydrate. 

Protein-rich food: 

Animal food — meat, eggs, dairy prod- 
ucts 97 95 98 

Vegetable food — legumes, dried . . 78 90 97 

Carbohydrate-rich foods: 

Cereals 85 90 98 

Sugars and starches . . 98 

Cellulose-rich foods: 

Green vegetables 83 90 95 

Total food: 

Mixed diet 92 95 97 

These values are for ordinary mixed diets. Special methods 
of preparation will modify them to a certain extent, e. g., when 
finely divided vegetable proteins were fed with starch and fat 
the utilization of these substances, in the dog, is very little 
less than that of meat, whereas according to Atwater's tables 
they are much less digestible. Degree of absorption does 
not, however, necessarily determine availability to the body, 
for a food which is completely absorbed may not be of the 
proper composition for its most economical utilization by the 
body (assimilation). 

When considering foods for the purpose of regulating a diet, 
we are usually concerned with the ease or rapidity with which 
they are digested. A food may be completely digested and 
still be "indigestible" in the sense in which this word is used 
with reference to the facility with which it is digested. Our 
measure of *' facility" is rather indefinite. It is ordinarily 
taken as the time required for a particular food to leave the 
stomach, because until comparatively recently we have been 
unable to study the processes which go on in the intestine 
from a time-relation point of view. The rapidity with which 
food is absorbed from the alimentary tract may also be 



DIGESTIBILITY OF FOOD 49 

accepted as an indication of the ease or difficulty with which 
a food is digested. The rate at which nitrogenous or carbon- 
aceous end-products are excreted has been used as an index 
of the rate of digestion and particularly of absorption. 

The rate of passage of food from the stomach has been 
systematically studied by Cannon, who showed that the three 
important food-stuffs, carbohydrate, protein and fat, in 
equal masses and of approximately the same consistency, 
when fed alone, leave the stomach at different, though char- 
acteristic, rates. Carbohydrate-rich foods passed out rather 
rapidly and appeared in the intestines in relatively large quan- 
tities. Protein did not begin to pass out of the stomach for 
some time. Once it began to appear in the intestines it came 
at a fairly uniform rate for a period of two or three hours. 
Fat also passed slowly from the stomach, more so than pro- 
tein. Mixtures of foods were ejected from the stomach at 
rates which were intermediate between those characteristic of 
the types of foods concerned. The opening of the pylorus is 
dependent upon the appearance of free acid in the antrum of 
the stomach and its closing upon the appearance of acid in 
the duodenum. A food which cornbines with acid, as protein, 
or which retards the secretion of the gastric juice, as fat, 
passes more slowly from the stomach than carbohydrate, a 
food which does not neutralize the acid. The order in which 
foods are ingested also affects the length of time required 
for the stomach to empty itself. A starchy food taken after 
protein food is retarded in its passage out of the stomach. 
Acid foods, those which do not absorb (neutralize) much 
acid, or those which stimulate the secretion of large quanti- 
ties of gastric juice, pass out more rapidly than foods which 
absorb considerable acid, are alkahne, or inhibit the secretion 
of gastric juice. Hence the rate of passage of food from the 
stomach is dependent upon the presence of free acid in the 
gastric juice. Exceptions to this general fact occur in disease 
— such as achylia in which the stomach empties rapidly. 

The consistency of the food likewise affects the rapidity 
with which it passes from the stomach: hard particles retard 
evacuation of the stomach; protein-food in lumps remains 
longer in the stomach than hashed protein, but is more com- 
pletely liquefied than the latter. Dilution of the food masses, 
on the other hand, does not retard their passage from the 
stomach. Practically no difference has been observed in the 
rate with which equal volumes of thick and watery mixtures 
of starchy foods are passed from the stomach; watery protein 
mixtures pass out more quickly than thick mixtures because 
of the smaller amount of protein present. 



50 DIGESTION, ABSORPTION AND EXCRETION 

London, using equal masses of solid food, found that the quan- 
tity of food remaining in the stomach after a definite period was 
the same whether a watery or partially desiccated food was fed, 
but that the degree of digestion was greater in the latter case. 
The water, apparently, tends to pass out of the stomach first. 
Groebbels found, however, that for dogs water ingested after 
bread doubles the time required for the food to leave the 
stomach, and that bread and water taken simultaneously 
remained even longer. The absolute amount of food taken 
determines, however, the length of time required for the 
complete evacuation of the stomach. 

Selection of the time required for a particular kind of food 
to disappear from the stomach, as a criterion of the ease or 
rapidity of its digestion is, as we have seen above, of doubtful 
value. To overload the intestine is undoubtedly as harmful 
as to overload the stomach. This is a more difficult matter, 
for the interrelation between the conditions in the intestine 
and the opening and closing of the pylorus are very intimate. 
Our knowledge of the factors affecting the rate of passage of 
foods from the stomach permits us, however, to select diets 
which are suited to the needs of the particular case under 
consideration. Thus a food, highly digestible from the quan- 
titative point of view, when fed in fairly large masses, would 
remain for a longer time in the stomach than when finely 
divided as in thick soup, and consequently the protein and 
perhaps the carbohydrate would be more completely digested 
before it passed into the intestines; this increased digestion in 
the stomach should tend to reduce the digestion required in 
the small intestine. The relative digestibility of particular foods 
will be discussed when they are taken up. 



CHAPTER II. 

ENERGY REQUIREMENT. 

The energy utilized by man in the performance of work and 
in the maintenance of body temperature is derived from the 
oxidation of the various food-stuffs in the body, particularly 
carbohydrates and fats. Extensive studies of animal and 
human metabolism have demonstrated that the law of con- 
servation of energy holds for the living organism just as it 
does in the inanimate world. The performance of a definite 
amount of work or the maintenance of a definite temperature 
involves the transformation of amounts of potential energy 
into kinetic energy equivalent to the work performed or the 
heat produced. Life is accompanied by the continual per- 
formance of work in one form or another. A knowledge of 
energy changes in the various conditions and states of life is 
fundamental to a satisfactory understanding and control of 
the diet. 

CALORIC VALUE OF FOOD-STUFFS. 

Oxidation, or combustion, of food-stuffs is accompanied by 
the liberation of energy in the form of heat. When this process 
takes place under properly controlled conditions, it is found 
that for each unit of material oxidized a definite quantity of 
heat is liberated. The measure of heat is the calorie; the heat 
required to raise the temperature of i gram of pure water i 
degree at 15° C. Since this is a relatively small unit, for con- 
venience the kilo calorie or Calorie is used, i. e., the quantity 
of heat required to cause the same change of temperature in 
one Hter (kilogram) of water. ^ Typical food-stuffs measured 
by this standard yield definite though different amounts of 
energy. 

^ Determinations of the calorific value of foods are conducted with the bomb 
calorimeter. Dried food is placed in a closed metal bomb, lined with a virtually 
unoxidizable metal, such as platinum or gold, charged with oxygen under great 
pressure. The bomb is then immersed in a known weight of water contained in 
receptacle of insulating material to prevent the rapid loss of heat. The food is 
ignited with a small piece of iron wire heated by an electric current. In the 
presence of the large excess of oxygen combustion proceeds rapidly to comple- 
tion and the heat developed increases the temperature of the surrounding water. 
The amount of increase is determined by means of an accurate and sensitive 
thermometer. The caloric value of the food is then calculated from the observed 
change, with proper corrections for radiation, etc. 



52 ENERGY REQUIREMENT 

Investigation of the body processes has shown that the pro- 
duction of body heat and of work are accomplished at the 
expense of energy obtained by reactions entirely similar to 
those observed in the calorimeter. The quantity of heat 
liberated and the end-products of the complete oxidation of 
carbohydrate or fat are entirely analogous to those obtained 
by experimentation outside the body. But since the end- 
products of complete utilization of protein in the body — urea, 
creatinine, uric acid, etc. — are themselves capable of being 
burned with the liberation of energy, the energy derived by 
the body from protein is less than that obtained in the 
calorimeter. 

In calculating the amount of energy derived from the food 
by the body we must consider that food as eaten is not 
entirely digested nor is the absorption from the intestinal 
tract complete. If allowance is made for that portion of the 
food-stuff which is not assimilated (approximate values: car- 
bohydrate 2 per cent., fat 5 per cent., protein 8 per cent.), 
and for variations in degree of utilization, we may assume the 
physiological fuel values as 4.1 Calories per gram for carbo- 
hydrate, 9.3 Calories per gram for fat, and 4.1 Calories per gram 
for protein. Knowing the relative proportions of these pri- 
mary food-stuffs in any food, we can calculate, with the above 
values, the approximate quantity of heat energy, which the 
body may derive from it. Most of the fuel values of foods 
presented in the various tables in this book are computed in 
this manner. 

In the calculation of diets the fuel value of food is usually 
expressed in two forms: {a) the number of calories available 
from a given weight of food, as the pound or gram, and {h) 
the weight of food (grams, ounces, or pounds) which will yield 
a certain number of calories, 100 Calories (kilo-calories) or 
1000 Calories (kilo-calories). The first method of recording 
unit values is most useful in calculating the caloric value of 
a diet which has been consumed as in statistical investiga- 
tions of diet, or where the food is taken ad libitum. When it 
is desired to prepare a diet having a given caloric value from 
a diet list composed of dishes of known weight and composition, 
the second procedure is particularly satisfactory. 

One Hundred Calorie Portion. — The 100 Calorie portion, or 
the weight of food which will supply 100 large calories, has 
been suggested by Fisher as a unit for comparisons. This 
unit is useful in comparing not only the relative nutritive 
value of various foods but also their cost. The use of this 
unit facilitates the preparation of diets in which foods of the 
same types may be substituted one for another to avoid 



CALORIC VALUE OF FOOD-STUFFS 53 

monotony. The proportions of protein, carbohydrate, and 
fat which furnish energy are expressed in terms of percent- 
ages, an arrangement which permits rapid calculations in the 
selection of a properly balanced diet. 

The lOO Calorie portion can be used advantageously in the 
preparation of diets only when slight variations are not impor- 
tant, since the results are expressed in terms of portions or 
individual pieces; variations will occur in the interpretation 
of a portion, composition of food, etc. When the portions are 
weighed out exactly the accuracy is increased, but then the 
usefulness of the method is not reahzed, for it is designed as a 
ready measure of the caloric value of the diet. Books^ con- 
taining data for the composition of various prepared dishes 
and their equivalent caloric yields and protein contents, the 
percentage of calories in the form of fat and carbohydrates 
and of protein are now obtainable. With such data a fairly 
accurate diet may be prepared by serving definite propor- 
tions of the total recipe after it has been prepared. ^ 

Combustion of food-stufFs in the calorimeter is initiated by 
means of a red-hot wire and continued rapidly in the pres- 
ence of heat developed as the result of the primary oxidation. 
Had we been able to observe the reaction, we should have 
noted an intense momentary production of heat. Combus- 
tion of food in the body, on the other hand, involves smaller 
masses of food, molecular in size, and the total quantity of 
energy liberated in one place and at any moment is neither 
as great nor as intense as in the calorimeter. The oxidation 
proceeds in stages: thus a molecule of glucose is oxidized grad- 
ually, passing through a number of different and successively 
simpler compounds before it is finally converted into carbon 
dioxide and water. Enzymes (oxidases) facilitate these pro- 
cesses; the extent and rapidity of which are controlled by a 
close interrelation of numberless enzymic and physical fac- 
tors. The result is the gradual liberation of heat under the 
most favorable conditions for bodily acitivity. 

Proteins, carbohydrates, and fats all yield energy when 
utilized by the body. 

Determination of Energy Requirement. — Heat liberated by 
an organism in the course of its activites can be estimated in 

^ Jurgenson, Kochlehrbuch und praktisches Kochlehre, 1910. Cooper, The 
New Cookery, Battle Creek, Michigan, 1916. Rose, Feeding the Family, New 
York, 19 16. 

2 The use of the data obtained by Gephart and Lusk (Analysis and Cost 
of Ready to Serve Foods, Jour. Am. Med. Assn., 191 5), in conjunction ^yith the 
purchase of food at the particular restaurants concerned will serve to increase 
the knowledge of a patient with regard to the relative food values of various 
prepared dishes. 



54 ENERGY REQUIREMENT 

two ways: directly by measurement with a calorimeter (direct 
calorimetry) and indirectly, through the measurement of the 
oxygen consumed and the carbon dioxide excreted (indirect 
calorimetry); by means of a respiration apparatus. A combina- 
tion of the two procedures is often pursued. In the first case 
the subject is placed in a room constructed on the same gen- 
eral principle as a bomb calorimeter; the calorimeter most 
used in this country (Atwater, Rosa, Benedict) is of the adia- 
batic type, i. e., the temperature of the walls is kept practi- 
cally constant and the heat given ofF by the subject is absorbed 
by water circulating through metal coils zvithm the chamber. 
The volume of water passed through the pipes and the increase 
in temperature are noted and from this data the heat evolved 
is calculated, with suitable corrections. To this result must 
be added the heat carried by vaporized water which is calcu- 
lated from the water absorbed from the air which has circu- 
lated through the chamber. This type of apparatus differs 
from the bomb calorimeter, in which the heat evolved is 
absorbed by water surrounding the chamber. 

Respiration Apparatus. — ^The respiration apparatus is a 
closed, air-tight chamber in which the subject is placed and 
through which is circulated a current of air. The products 
of oxidation, carbon dioxide and water, are removed from the 
air by absorption, by soda lime, and sulphuric acid respec- 
tively as they pass from the chamber. These determinations 
are made either on the total volume of air or from an aliquot 
portion. Knowing the composition of the entering air and 
the amount of carbon dioxide and water produced during the 
experiment, the extent of oxidation can be calculated. In the 
Atwater-Rosa-Benedict apparatus the respiration apparatus 
and calorimeter apparatus are combined. In this case the 
air passed through the apparatus is circulated through a 
closed system. Oxygen is added to the air just before it enters 
the chamber, and carbon dioxide and water are removed after 
it has passed out of the room. By this method not only the 
carbon dioxide and water given off can be determined but 
also the absolute amount of oxygen used by the subject can 
be measured. Comparison of the results of direct calorimetry 
with the calculated values from CO2 excreted and oxygen 
consumed has shown them to be comparable and for short 
periods — 2 or 3 hours — the latter method yields results which 
are perhaps more accurate. 

A less elaborate type of respiration apparatus is also in 
use, in which the subject breathes through a closed system of 
the same general nature as that described above without 
being confined in a specially constructed room. 



BASAL METABOLISM 55 

Respiratory Quotient. — The oxidation of different types of 
food-stuffs involves combination with various quantities of 
oxygen and the liberation of variable proportions of carbon 
dioxide. According to Avogadro's law equal volumes of 
gases under the same conditions of temperature and pressure 
contain equal numbers of molecules; hence, when in the oxi- 
dation of an atom of carbon a molecule of oxygen (O2) is used 
and a molecule of carbon dioxide (CO2) is produced, no change 
occurs in the volume of the reacting gases provided the 
system is returned to the original temperature and pressure. 
Since carbohydrates contain sufficient oxygen to form water 
with the hydrogen present in the molecule, combustion there- 
fore involves only the oxidation of the carbon present, conse- 
quently the ratio of carbon dioxide produced to oxygen con- 
sumed ^ is I. Fats, on the other hand, do not contain suffi- 
cient oxygen to combine with their hydrogen to form water, 
and oxygen is utilized for this purpose in addition to that 
used in the oxidation of carbon. The ratio of ^ is therefore 
less than i, in this case approximately 0.7. Protein is inter- 
mediate between fats and carbohydrates in its state of oxida- 
tion. Its ^ ratio is therefore less than one, approximately 
0.8. 

From data obtained with the respiration apparatus the ratio 
of carbon dioxide formed to oxygen consumed can be calcu- 
lated; this ratio is designated the respiratory quotient. A 
high respiratory quotient (above 0.8) is taken as evidence of 
the utilization of considerable quantities of carbohydrates, a 
low quotient (near 0.7) as evidence of the extensive utiliza- 
tion of fat by the body. When carbohydrate is transformed 
into fat, oxygen is derived from the carbohydrate and the 
respiratory quotient may be greater than i, whereas in the 
case of diabetes, protein is converted into carbohydrate and 
excreted in the urine, less oxygen is excreted as CO2 than would 
normally be the case, and the respiratory quotient may be less 
than 0.7. Results obtained through the calculation of such 
quotients have been of great value in indicating the differ- 
ential utilization of food-stuffs in the body. 

Basal Metabolism. — Two methods of attack have been em- 
ployed in determining the total quantity of energy required and 
the relative proportions of the food-stuffs most suitable for indi- 
viduals under varying conditions. One, the statistical method, 
consists in estimating, from observations of a large number of 
individuals the average quantity and composition of the food 
eaten by normal individuals during comparatively long periods 
of time. Such experiments have been carried out in many 



56 ENERGY REQUIREMENT 

countries and upon groups of individuals employed in different 
occupations. These data form a very substantial basis for our 
deductions regarding the food requirements of man. 

The second and more exact method is to determine by 
means of a calorimeter, or respiratory apparatus, the energy 
exchange of the body under different conditions of activity 
and states of nutrition. A combined study of the energy 
exchanged and of the excreta, mcludmg the carbon dioxide and 
water expelled by the lungs (universal respiration apparatus) 
enables us to estimate the relative amounts of the various 
food-stuffs utilized by the body. Studies of this sort yield 
very definite results. The accuracy of these experiments 
tends to counter-balance the deficiencies arising from the 
smallness of the number, and the shortness of the periods of 
observation in this mode of investigation. Atwater, and later 
his collaborator, Benedict, have collected a large amount of 
data by both methods of investigation upon the dietetic 
habits of the American people. It is largely upon their results 
that our ideas of food requirements are based. ^ 

For the estimation of the energy requirements of different 
individuals and as a basis of comparison between them in 
experimental work it is essential to have some standard by 
which they may be measured. 

Such a standard in metabolism or basal energy require- 
ment is taken as equivalent to the heat liberated by a fasting 
man (12 to 15 hours after the last meal) when lying down, 
asleep and comparatively relaxed. It may be expressed in 
terms of the total daily energy requirement, or in smaller 
units, such as the energy liberated per kilogram of body weight 
or square meter of body surface in an hour. Values based on 
the unit of body weight are suitable only when comparing 
individuals of approximately the same size, shape and weight; 
since, in general, a greater amount of energy is produced per 
unit of weight by a small than a large organism. For the 
comparison of different individuals, as a man and a child, 
or of two men of different sizes, expressions of the energy 
metabolism, in terms of unit surface, are more accurate and 
comparable; the number of Calories per square meter per 
hour is usually selected as the unit of reference. 

The relative value of body weight and body surface as the 
basis of comparison between different individuals has recently 
been studied by Benedict and by DuBois and their co- 
workers. Benedict conducted investigations on the factors 

^ Benedict, Lusk, DuBois, Rowland and Murlin have recently contributed a 
large amount of work bearing upon the fundamental basis of energy exchange, 
basal metabolism, in the normal adult and child and in disease. 



BASAL METABOLISM 57 

which modify basal or standard metaboHsm. In order to 
ehminate the variable effects of muscular activity and the 
ingestion of food, the fundamental condition of comparison 
selected was the quiet resting metabolism of subjects in the 
postabsorptive condition. ^ From an analysis of the data 
obtained in a series of investigations conducted under similar 
conditions Benedict has shown that while the total body 
weight is an important factor in the quantity of heat pro- 
duced — large bodies give off greater amounts of heat than 
small ones — there is no direct relation between the total body 
weight and heat production. Comparisons of energy require- 
ments on the basis of Calories per kilogram of body weight 
per day tend to show that individuals of the smallest body 
weight have the highest heat production, the variations from 
this rule are, however, so great that it cannot be accepted as 
general. The metabolism of men and women when compared 
on the basis of the heat lost per unit of area, per square- 
meter per hour, is approximately constant. While accepting, 
for the present at least, the unit body surface as the basis of 
comparison Benedict believes that this is "due not to the loss 
of heat from the body surface but to the fact that the body 
surface is a better index of the general law of growth. Later 
we shall see that variations in the intensity of metabolism 
and the mass of tissue as indicated, for example by age and 
muscular development, are associated with deviations from the 
"normal" basal metabolism. DuBois has studied the relation 
of body surface and basal metaboHsm, and as a result, advo- 
cates the use of body surface as the basis of comparison between 
different individuals. His conclusions are based upon data 
obtained from the measurements of the energy exchange and 
of body surface; the latter was determined by a new and more 
accurate method than any hitherto described. 

With the aid of this data DuBois has shown that Meehs' 
formula^ for calculation of body surface which has been in 
general use, does not give accurate results for any but a 
selected (average) group of individuals. DuBois and DuBois^ 
have derived a formula (linear formula) in which only linear 
measurements are concerned; determinations of length and 
circumference. This formula necessitates a number of careful 
observations and calculations. For any but the most exact 
work the following simple formula may be used. It involves 

-The "postabsorptive condition" is held to be attained twelve to fifteen 
hours after the last meal. 



2 Meehs' formula: S = Cv W^ where S is surface; W, weight and C a con- 
stant dependent upon the shape and density of the solid; for man C is 12.3. 

3 Arch. Int. Med., 1916, xvii, 855. 



58 



ENERGY REQUIREMENT 



M 



88 



WEIGHT— POUNDS 
110 132 154 176 



198 




50 60 70 80 

WEIGHT- KILOGRAMS 



90 



100 



110 



Fig. I . — Chart^ for determining the surface area of man in square meters from 
weight in kilograms (Wt.) and height in centimeters (Ht.) or their equivalents 
in pounds and inches, according to the formula: 

Area (sq. cm.) = Wt. o-425 x Ht. O'^^s x 71.84. 



Standards of Normal Metabolism. Average Calories per Hour per 
Square Meter of Body Surface.^ 



Subject, 
age in years. 

Boys, twelve to thirteen 
Men, twenty to fifty . 
Women, twenty to fifty 
Men, fifty to sixty . 
Women, fifty to sixty . 



According 


According to linear and 


to Meehs' 


height-weight 


formula. 


formulas. 


45-7 


49-9 


34-7 


39.7 


32.3 


36.9 


30 8 


35-2 


28.7 


32.7 



GAL. 
50 


/ 


\ 
































/ 


\ 


■ — \ 


































\ 






























40 








V 




























30 































^^^^^ 








































20 






































































10 






































































n 





































30 



60 



Fig. 2. — Variation of basal metabolism with age: Calories per square meter 
of body surface per hour. Only the results of male subjects were used in making 
this curve; the metabolism of female subjects is slightly lower. (Russel Sage 
Institute of Pathology.) 



^ DuBois and DuBois: Arch. Intern. Med., 1916, xxvii, p. 863. 
2 Gephart and DuBois: Arch. Int. Med., xvii, 913. 



CALCULATION OF ENERGY REQUIREMENT 



59 



Percentage Increase or Decrease in the Hourly Basal Metabolism for 

Various Factors Affecting the Extent of Energy Metabolism. 

(Adapted from the Work of Lusk and DuBois.) 



Average man, 154 pounds (70 kg.), 

at complete rest, 70 Calories per 

hour: 
Ingestion of food 
Lying in a chair, supported 
Sitting up in chair . 
Moderate activity in chair 
Very restless in bed 
Exercise : 

Walking on level, 2.7 miles per 
hour 

Climbing, 2.7 miles per hour . 

Hard labor, bicycle riding . 

Thin but healthy 

Fat but healthy 

Disease : 

Most patients not seriously ill 



Increase or decrease, 
per cent. 



5 to 10 
O 

8 

29 

20 to 100 



230 

580 

756 

o 

o 



+ 10 to 



Additional Calories per 
hour for average man. 



Increase. 



10 
10 



Obesity +10 to 

Diabetes with severe acidosis . o to 15 

Severe pernicious anemia . . o to 20 

Acromegaly o to 30 

Cancer, severe heart and kidney 

disease and high fever . . 20 to 40 

Leukemia 30 to 60 

Typhoid fever 46 to 50 

Convalescence 10 to 20 

Exophthalmic goitre: 

Mild 25 to 50 

Severe 75 to 100 

Prolonged undernutrition . . —10 to —30 

Diabetes, emaciated . . . —10 to —35 

Cretinism and myxedema . . —25 to —50 



Decrease. 



4 to 7 



6 

20 

14 to 70 


160 
407 

529 




+7 to -7 

+7 to -7 

to 10 

to 14 

to 21 


14 to 28 

21 to 42 

28 to 35 
7 to 14 


18 to 35 
53 to 70 


— 7 to —21 
-7 to -25 
-18 to -35 



Example: Man, aged fifty to sixty years; height, 67 inches (170 cm.); weight, 
154 pounds (70 kg.); office work most of day (fourteen hours) ; walks two hours; 
bed, eight hours. 

Calories per hour. 

(a) Area, from chart, 1.8 square meters. 

(b) Basal metabolism per square meter of body surface 

(Table, p. 58, man 50-60) 35.2 

(c) Basal metabolism of 1.8 X 35.2 63 . 4 (drop 0.4) 

(d) Increase for food, 10 per cent, (used in all calcula- 

tions), 63 X o.i 6 

(e) Increase for bed, resting basal metabolism plus food 

(c + d), or 63 + 6 69 

(/) Increase for office work, moderate activity in chair, 

29 per cent.; 63 X 0.29 18 

(g) Increase for walking (on level), 230 per cent.; 

63 X 2.3 145 

Then for the day: Calories per day: 

Bed: Eight hours = (c + d) X 8 or (63 + 6) X 8 . 552 
Office work: Fourteen hours = (c + d + f) X 14 or 

(63 +6 + 18) X 14 1218 

Walking: Two hours = (c + d + g) X 2 or (63 + 6 + 

145) X 2 428 

Total for day 2 198 



60 ENERGY REQUIREMENT 

but two factors, height and weight (height-weight formula) : 
A = W^'^25 X ^Q'Ti^. X 71.84, where A is the area in square 
centimeters; H, height in centimeters, and W, weight in kilo- 
grams. With this formula, or more conveniently with the 
chart on page 58, the extent of body surface can be readily 
calculated. 

The errors in the linear formula and the height-weight 
formula have been estimated at a maximum of =t: 5 per cent., 
average =*= 1.5 per cent, while Meehs' formula gives a variation 
of ± 30 per cent., average 15 per cent. The maximum devia- 
tions obtained with DuBois' formula apply particularly to 
those of unusual shape. Benedict has recently corroborated 
the greater accuracy of the DuBois formula. 

While the basal metabolism of various individuals is nearly 
the same per square meter of body surface, such a compari- 
son is not exact in all cases. The deviations from the general 
rule indicate that other factors such as activity, size, age, and 
training modify the rate of basal metaboHsm. In considering 
the energy requirements of an individual, therefore, the effect 
of these factors must be recognized, even though we do 
not have at present the necessary data to correct them 
in our estimations. Sufficient data have been collected with 
regard to age to indicate the trend of the variation and to 
permit the use of such data in calculating energy require- 
ments during certain periods of life. Benedict holds that 
*'the basal metabolism is a function of both the total mass of 
active protoplasmic tissue and of the stimulus to cellular 
activity existing at the time the measurement of metabolism 
is made." Body composition, i. ^., proportion of active proto- 
plasmic tissue to the inert body fat, has an effect upon the 
basal metaboUsm, thus the tendency of athletes toward a 
higher metaboHsm when compared with non-athletes is to be 
ascribed to their greater muscular development; the lower 
metabolism of women than of men, about 6 per cent., is 
apparently associated with their greater proportion of inert 
body fat (lower muscular development) and not entirely to 
an inherent characteristic of sex; tall persons have a greater 
metabolism than short individuals since they have propor- 
tionately greater amounts of muscular tissue. Another factor 
that modifies the basal metabolism, stimulation of cellular 
activity is influenced by a number of factors: age, sleep, 
character of preceding diet and after-effects of severe muscular 
work; there are also variations in the diurnal as well as day- 
to-day metabolism. 

The effects of age have been more extensively studied than 
the other factors which affect the basal metabolism. The 



BASAL METABOLISM 61 

active youth has a higher rate of metaboHsm than a person 
in middle Hfe, while an old man has a still lower metabolism. 
The metabolism of an infant is low during the first month, 
after which it becomes much. higher. In childhood the basal 
metabolism is above that of the adult, with increasing age 
the rate of metabolism decreases until it reaches that of the 
adult at about 20 years of age; there is a slight rise at about 
puberty. The chart on page 58 indicates the variations 
in basal metabolism with age. In calculating the metab- 
oHsm of persons of different ages the standards of normal 
metabolism proposed by Gephart and DuBois may be used 
(p. S8). 

Daily habits affect the energy changes. A fasting subject 
lying perfectly still immediately after waking in the morn- 
ing has been shown to have an average metabolism which 
was 13 per cent, higher than when asleep. Later in the day 
under similar conditions the metabolism increases to 22 per 
cent, above the resting state. Prolonged fasting results in a 
lower metabolism than before fasting. Severe muscular work 
results in a continued higher rate of metabolism some time 
after the cessation of work. These variations have been 
ascribed by Benedict, as indicated above, to an alteration in 
the stimulus to cellular activity. 

In addition to the factors which modify the basal metab- 
oHsm there are others which have a direct effect upon the 
total daily metaboHsm: food, activity, temperature and dis- 
ease. The ingestion of food causes an increase in the rate of 
metabolism. Experiments upon fasting men and animals 
have established the fact that after the removal of the effect 
of the previous diet, which affects metaboHsm during the first 
part of a fast, the energy production is low and practically 
constant. 

If to such an organism food be given, there will be an increase 
in the basal energy metabolism which will vary with the kind 
and quantity of food ingested. Protein exerts a greater stimu- 
lation than carbohydrate or fat. Small quantities of food will 
increase the basal energy metabolism from 5 to 10 per cent. 
While following the ingestion of large quantities of food, the 
increase may be as high as 40 per cent. This increase begins 
in the case of proteins and carbohydrates, in from a half-hour 
to an hour after the ingestion of food, while following the 
ingestion of fat there is little increase until 5 or 6 hours after- 
ward. The increase in the basal metabolism following the 
ingestion of food is designated as the specific dynamic effect 
of food. The effect of protein has been shown by Lusk to be 
due to a stimulation of the metabolism of the cells by certain 



62 ENERGY REQUIREMENT 

of the amino-acids. The effect of carbohydrate and fat, on 
the other hand, is due to the mass action of these food-stuffs 
in the circulation — as the result of plethora. Benedict has 
also suggested that this increased metaboHsm is the result of 
stimulation of cellular activity. 

Muscular activity has a direct effect upon the energy 
requirement of an individual. In studying the basal energy 
metabolism of a fasting man, as indicated above, it was found 
that the metabolism was increased 13 per cent, above that of the 
sleeping metabolism merely as the result of being awake, and 
that continued mental activity and prolonged muscular activity 
resulted in a further increase of 9 per cent, in the basal metab- 
olism measured under conditions of complete repose later in 
the day. As the intensity of activity increases there is a pro- 
portionate increase in the energy exchange. Energy-yielding 
food must be supplied to meet this increase. 

Training in the performance of work has a tendency to 
reduce the energy requirement for a given piece of work. The 
beginner makes a greater effort to perform his work, for many 
false motions are made; the result is an increased metab- 
oHsm. Experience and routine gradually reduce the number 
of unnecessary movements with a corresponding reduction in 
the energy exchange. 

Studies of the relative efficiency of the human body — the 
proportion of energy contained in food which is transformed 
into work — shows the body to be a very efficient machine. 
Experiments in which a man rode a specially constructed 
bicycle, by means of which the work performed in riding could 
be measured, showed that 35 per cent, of the total energy 
transformed during muscular work was used in the accom- 
plishment of the work. In general, however, the efficiency of 
the body in converting the potential energy in the food into 
work is found to be approximately 20 per cent. 

To meet the increased energy requirement which accom- 
panies muscular activity the body must be supplied with 
greater quantities of energy-yielding food. Protein metab- 
olism, as we will show later, is not increased to any extent 
during work provided sufficient fat and carbohydrate are 
present. Fat is capable of yielding a greater quantity of heat 
per gram than carbohydrate. Carbohydrate, on the other 
hand, is apparently more readily oxidized in the body. Studies 
of the respiratory quotient during work has demonstrated an 
increased utilization of carbohydrate at such times. These 
observations indicate that the stores of carbohydrate are 
being utilized for the performance of work in preference 
to the fats. The use of carbohydrate as a prime source of 



BASAL METABOLISM 63 

energy is emphasized by the fact that following the cessa- 
tion of work the body appears to be subsisting in the pres- 
ence of a depleted store of carbohydrates (Benedict). 
Other experiments show, however, that fat is capable of sup- 
plying the energy requirement of the body, particularly in 
the presence of small quantities of carbohydrate. In a sud- 
den burst of activity, then, carbohydrates are more satisfac- 
tory than fats. In long-continued activity the fats which are 
apparently oxidized with difficulty are extensively utilized. 
Where there is an excessive prolonged energy requirement, 
such as in continuous severe labor and in cold climates, an 
increase in the more concentrated fats irf the diet is desirable; 
for, were the heat derived entirely from carbohydrates it 
would entail an excessive ingestion of vegetable food. 

Age, with its variation in the processes of metaboHsm — in 
the young the predominance of anabolic over catabolic func- 
tions (formation of new tissues) continuous activity and greater 
rate of metabolism as contrasted with the slower movements, 
lowered rate of metaboHsm and muscular tone accompanied 
usually by decreasing weight in the aged — exhibits a variation 
from the requirements of the average adult in the prime of life. 

Disease affects the basal metaboHsm; it may be increased 
as in exophthalmic goitre (Graves's disease) 75 to 100 per cent.; 
in typhoid fever, 40 to 50 per cent.; in anemia, cancer, severe 
cases of heart and kidney disease and high fevers, 20 to 40 
per cent.; it may be decreased as in cretinism and myxedema 
20 to 50 per cent.; or it may approximate the normal rate as 
in diabetes. Considerations of the energy requirement in 
various diseases will be found in discussions relating to them. 
It is an interesting fact that in typhoid fever when the basal 
metaboHsm is markedly increased, the ingestion of food is not 
accompanied by a marked increased heat production or spe- 
cific dynamic effect. This fact is of importance, for it permits, 
on a scientific basis, the feeding of fever patients with the 
large quantities of food necessary to meet the requirements of 
their increased metabolism without fear of materially augment- 
ing the metaboHsm because of the inherent stimulating effect 
of the food itself. 

To summarize our discussion: The energy metabolism of 
various individuals of different sizes may be quite accurately 
compared on the basis of the extent of their body surface. 
The intensity of metabolism varies with the mass of active 
protoplasmic tissue and the stimulation to cellular activity 
as represented, for example, by sex and age. Food-stuflTs have 
their specific effects upon the rate of heat production. The 
varied activities of life aside from those included in the basal 



64 ENERGY REQUIREMENT 

metabolism are associated with an extra expenditure of energy. 
Evaluations of the daily average metaboHsm include allow- 
ances for all such variations in activity and they must be 
used accordingly. 

The table on p. 59 gives the percentage increase in metab- 
olism and the Calories per hour for the average man, which 
must be added to his hourly basal metabolism (70 Calories per 
hour) according to the nature of his activity. 

Atwater and Benedict have suggested the following values 
to represent the average rate of metabolism of the average 
man under various conditions of activity: 

Calories 
per hour. 

Man sleeping 65 

Man sitting at rest 100 

Man at light muscular exercise . 1 70 

Man at active muscular exercise 290 

Man at severe muscular exercise 450 

Man at very severe muscular exercise 600 

In estimating the daily energy requirement of a man the 
day is considered as being made up of a number of periods of 
various types of activity whose hourly energy transformations 
are approximately known. The total requirement is, then, a 
summation of these hourly transformations. Such calculation 
of the heat exchange has been made for an average man at 
Hght muscular work, taking into consideration the variation 
in activity. 

Calories Heat 

per hour. output. 

At rest, sleeping eight hours 65 520 

At rest, awake, sitting up six hours . . . . 100 600 

Light muscular exercise ten hours .... 1 70 1 700 

Total output of heat for twenty-four hours 2820 

The daily energy requirement of man under various condi- 
tions has been given by Lusk as follows: 

Calories 
per day. 

In bed twenty-four hours; absolute rest without food . . 1,680 

In bed twenty-four hours; absolute rest with food . . . 1,840 
In bed eight hours; work in which sitting in a chair, sixteen 

hours; with food 2,170 

In bed eight hours; in a chair fourteen hours, moderate exer- 
cise, two hours 2,500 

In bed eight hours; in a chair fourteen hours, vigorous exercise 

two hours; with food 3,000 

Farmer, active exercise . . ' 3.500 

Lumberman 5,000 

Rider in a six-day bicycle race 10,000 



ENERGY REQUIREMENT 65 

The following daily energy requirements for infants and 
children have been suggested. 

Energy Requirements for Children, 

Total Calories 
per day. 

1 to 2 900 to 1200 

2 to 5 1200 to 1500 

6 to 9 1400 to 2000 

10 to 13 1800 to 2200 

^ fgirls 2200 to 2600 

^ '\boys 2500 to 3000^ 

Atwater has given comparative values for the metabolism 
of the different members of a family. On the basis of the 
father having a rate of i, the energy requirements of the rest 
of the family would be : 

Father i . o 

Mother 0.8 

Sons: 14 to 17 0.8 to 1.5 

Daughters: 14 to 17 o.7toi.o 

Children: 10 to 13 o.6toi.o 

6 to 9 0.5 

2 to 5 0.4 

Under 2 0.3 

1 Lusk and Gephart have found, from a study of the food eaten by boys in 
a fashionable boarding school, that an active boy may consume food equivalent 
to 4000 to 5000 Calories per day. 



CHAPTER III. 
PROTEIN REQUIREMENT. 

In our previous discussions, as well as in our subsequent 
discussions relating to protein-rich foods, we have taken up 
the composition of protein material in general, its digestion, 
absorption, and the change which it undergoes in the process 
of assimilation. At present we are concerned with the quan- 
titative relation of protein in the diet and the factors which 
influence this. 

Protein as we have already found, is an essential constit- 
uent of our daily dietary. Energy may be derived from pro- 
tein, fat or carbohydrate but only protein or its products of 
hydrolysis can furnish the amino-acids necessary to replace the 
loss of nitrogenous material in the tissues resulting from the 
general bodily functions or for the constructive processes of 
growth. 

The necessity for the presence of protein in the dietary was 
early recognized. It was, in fact, a more difficult task to demon- 
strate that this food constituent was concerned more particu- 
larly in the structural changes of the body than primarily as 
a source of energy for muscular work. We no longer say, as 
did Liebig, that protein is the source of muscular energy, but 
recognize that this function belongs to the carbohydrates and 
fats, and consider protein as the chief source of material for 
the repair of the wear and tear in the muscles and other parts 
of the body. 

Admitting that the necessity for protein is so well estab- 
Hshed that it is practically self-evident, we may take up the 
question of the quantity of protein necessary for the body, 
how it may be suppHed, and relative efficiency of protein for 
the needs of the body. 

Methods employed for the study of these problems are in 
general the two considered in our discussion of the energy 
requirements of the body: the purely experimental and the 
statistical. In the experimental studies use is made of the 
nitrogen balance or of the rate of growth of young animals, 
such as rats, when compared with the normal rate of growth. 
For the determination of the nitrogen balance the nitrogen 
content of the food — representing the protein material — feces. 



PROTEIN REQUIREMENT 67 

urine, and in some cases the hair, scurf and excretions from 
the skin, are analyzed for definite periods of time. The quan- 
tity of nitrogen found in all of the excretions is then sub- 
tracted from that in the food. If the result is a positive fig- 
ure, that is, if there is less nitrogen in the excretions than in 
the food, then the subject is said to have a positive nitrogen 
balance, for he has retained in his body a certain amount of 
nitrogen-containing material. If the result be a negative 
value, i. <?., more nitrogen in the excretions than was contained 
in the food, the subject has supplied nitrogenous material 
from his tissues and is said to have a negative nitrogen bal- 
ance. A normal adult is usually in an approximate nitrogen 
equilibrium. During growth and regeneration — youth, preg- 
nancy and convalescence — the organism normally shows a 
positive balance. In conditions of emaciation, fever or wast- 
ing diseases a negative balance is obtained. 

The average daily protein metabolism or plane of nitogen 
equilibrium varies in the same individual, according to the 
quantity of protein ingested. A sudden change from a low 
to a high protein diet, or vice versa^ is not accompanied by an 
equally abrupt variation in the daily excretion of nitrogen. 
Instead there is a gradual increase or decrease in the quantity 
of nitrogen eliminated until the new plane of metabolism is 
finally attained and the subject is once more in nitrogen 
equiHbrium. When the protein food is completely removed 
from the diet the total nitrogenous excretion is an index of 
the internal, or endogenous, metabolism of the individual. 

An exact determination of the endogenous protein metab- 
olism of man is the ideal basis for the study of the needs of the 
body. This is a difficult procedure, for many contributing 
factors modify the quantity of nitrogen excreted — our measure 
of the rate of the protein metabolism. When all of the food 
elements are removed as in fasting, we might expect to obtain 
a measure of the endogenous protein metabolism. Experi- 
ments upon men and animals have shown, however, that this 
is not the case, for a number of modifying factors, such as 
the previous diet and the quantity of fat and carbohydrate 
(glycogen) present in the body, will modify the course of 
the cellular activities and the protein metabolism. 

The plane of protein metabolism in the early stages of fast- 
ing is aflFected by the previous dietary regimen. When this 
diet has been rich in protein, a larger quantity of nitrogen is 
excreted in the urine than would have been obtained had the 
diet been poor in protein — just as with a normal diet, if the 
protein quota be decreased, the nitrogenous excretion changes 
gradually and not abruptly from one level to another. It is 



68 PROTEIN REQUIREMENT 

evident, therefore, that it would not be accurate to accept 
the quantity of nitrogen excreted in the early part of a 
fast as a measure of the endogenous protein metabolism. 
Neither can we accept the nitrogen excreted after the effects 
of the previous nitrogenous diet have passed, for during this 
period of readjustment other factors have been developing 
an abnormal influence. The normal man is accustomed to 
derive the greater portion of his energy from the oxidation of 
carbohydrates and fats. A fast is commenced with a small 
reserve of carboh^/^drate, glycogen, and a somewhat larger 
reserve of fat. During the first few days, while the effects 
of the previous diet have been disappearing, practically all of 
the glycogen reserve has been utilized and after this the body 
subsists upon a diet, so to speak, of fat and protein. The 
removal of carbohydrate material from the diet of a man who 
is accustomed to this food element in his diet results in a 
disturbance of his metabolism, particularly a change in the fat 
metabolism. Under such conditions the body seems to be 
unable completely to oxidize fats. Partially oxidized fatty 
acids are passed into the blood stream and these cause a 
disturbance of the equilibrium between the acidic and basic 
radicles which has its eflPect upon the respiratory and salt 
metabolism and ultimately, if not directly, upon the protein 
metaboHsm. We have evidence of the incomplete oxidation 
in the beta-hydroxybutyric and aceto-acetic acids, in the 
urine, and of a disturbed equilibrium in the mcreased ammonia 
and acidity of the urine. Such disturbances are experienced 
not only in fasting man but in diabetes, in which there is a 
failure to oxidize glucose, and they have been demonstrated 
experimentally by feeding a carbohydrate-free diet to men 
and to animals accustomed to a carbohydrate-rich diet. 
Acidosis increases the rate of protein metabolism. In fasting 
a further increase of protein metabolism results when the fat 
supply is reduced and the organism is forced to utilize protein 
material as a source of energy. A measure of endogenous 
metabolism cannot therefore be obtained b}^ means of fasting 
experiments. 

A study of the metabolic changes on a protein-free diet 
containing carbohydrates, fats and salts in the proper pro- 
portions is perhaps a better index of the endogenous protein 
metabolism. This procedure is also open to question for 
under these conditions the body is supplying from its own 
tissues the protein material needed for repair. 

Studies of the endogenous protein metabolism show that 
the average man metabolizes from 0.04 to 0.03 gram of 
nitrogen per kilogram of body weight — 2.1 to 2.8 grams of 



PROTEIN REQUIREMENT 



69 



Glutamic 




acid. 


Lysine. 


43-7 


0.15 


26.2 





13.0 


3 03 


15-6 


6.00 


16.8 


6.00 


155 


7.60 


10. 1 


750 



nitrogen for a 70-kilogram (154 lb.) man — in the form of pro- 
tein in the processes associated with the general wear and tear 
of the body. 

In constitution the protein molecule varies in both the 
quantity and the kind of amino-acids according to its source. 
If we compare the quantities of amino-acids in certain pro- 
teins we see that were a man to eat the vegetable protein, 
gliadin, alone he would have considerably more glutamic acid 
than was absolutely necessary, and to obtain sufficient lysine 
to form a protein of the approximate composition of, say, beef 
protein he would have to ingest a much larger quantity of 
gliadin than beef or other animal proteins. 

Protein. 
Gliadin , 
Zein . 
Legumin 
Casein 
Gelatin . 
Beef protein 
Fish protein 

The chemical structure of the protein ingested must there- 
fore be considered in determining the protein requirement. 
If the ingested protein contains a proportion of any essential 
amino-acid that is less than the quantity needed by the body 
or lacks the acid entirely, it becomes necessary for the body 
to synthetize the required amino-acid from other available 
acids or products, or to supply the amino-acids either by an 
increased ingestion of the protein itself, if the failure be due 
only to a lowered content, or by the ingestion of other pro- 
teins, or of the amino-acid itself if it be entirely absent. Con- 
versely, if the protein contain a greater proportion of certain 
amino-acids than the body can utilize they will not be used 
but deaminized, oxidized and the products excreted. 

Our knowledge of the synthesis of amino-acids in the body 
is very limited. Glycocoll is apparently synthetized and, 
under experimental conditions, perfusion of the liver, the 
formation of alanine, phenylalanine, and tyrosine have been 
demonstrated. The extensive synthesis of amino-acids in the 
body has not, however, been shown. Studies of such prob- 
lems are complicated by the possibility that apparent synthe- 
sis may be due to the formation of the amino-acid by bac- 
teria in the intestines and its subsequent utilization by the 
body. Synthesis of amino-acids with cyclic nuclei appears 
to be particularly difficult. The body cannot, then, be depended 
upon to supply the missing amino-acids; they must be added 
to the diet as such or in the form of protein containing them. 



70 PROTEIN REQUIREMENT 

The fact that gelatin cannot of itself satisfy the total pro- 
tein requirement is due to its lack of the amino-acids, trypto- 
phan, tyrosine, and cystine. The addition of tyrosine and 
cystine and tryptophan has been found to improve its value 
and make it satisfactory, for short periods at least. Experi- 
ments with growing rats have likewise served to demonstrate 
the effect of various quantities of amino-acids in the diet. A 
protein of corn, zein, which is deficient in the amino-acids, 
lysine and tryptophan, is found to be unable to support 
growth or even to maintain the rats without loss of weight. 
With the substitution of equivalent quantities of other com- 
plete proteins the rats grow normally. The addition of tryp- 
tophan to the zein diet serves to maintain the rats without 
growth; while the addition of both tryptophan and lysine 
makes the diet sufficient for both growth and maintenance. The 
importance of lysine for growth has been shown in experiments 
in which gliadin, a vegetable protein containing no lysine but 
tryptophan, was fed. The rats maintained their body weight 
but did not grow: the addition of lysine made the diet satis- 
factory. In one of Osborne and Mendel's experiments with 
gliadin a rat which failed to grow gave birth to a litter of 
young which grew at the normal rate on their mother's milk. 
Later these rats were fed different diets. Those which received 
complete proteins grew at the normal rate while one which 
received the diet fed to the mother failed to grow. From 
experiments of this nature carried out by Willcocks and 
Hopkins, Osborne and Mendel, and Hart and McCollum, it 
has become evident that, other necessary factors being pres- 
ent, the absence or a slight deficiency in the protein fed, of 
an amino-acid essential in cellular metabolism, determines 
the extent of tissue construction, or rate of growth. With the 
absence of such units the other amino-acids which would 
have been used in the formation of a protein molecule cannot 
be utilized; they may be used in some processes in the forma- 
tion of tissue or secretions not involving the missing radicle 
or are deaminized and oxidized. McCollum has suggested 
that the processes of repair do not necessarily involve the 
decomposition and synthesis of an entire protein molecule. 

The quantity of protein needed also depends upon other 
factors in the diet. McCollum in studying the presence of 
toxic substances in natural foods (wheat) and their effect 
upon growth found that protein tends to neutralize the effect 
of such substances. He explained his findings as follows: 
*'A single factor (protein) in a ration ma}^ appear to admit 
the maximum performance of the animal with respect to 
growth, without itself representing the optimum amount or 
character. When this circumstance prevails it ma\' entirely 



PROTEIN REQUIREMENT 71 

escape notice, yet if in another ration exactly like it, except 
that a second factor tends to injure the animal, nutritive fail- 
ure may result. In such a case as the latter the improvement 
of the protein factor by the addition of more protein or by 
the substitution of a better protein, the plane of protein intake 
remaining unchanged, the animal may make the maximum 
performance notwithstanding the unfavorable character of 
the injurious factor of the ration." This finding is an argu- 
ment, in general, for a high rather than a low protein diet 
whenever the protein is not carefully selected. 

The addition of protein nitrogen in amounts equivalent to 
the basal nitrogen requirement, to a diet containing a suffi- 
cient quantity of fat and carbohydrate may not necessarily 
serve to prevent a loss of protein from the body. This may 
be due to the nature of the protein as already discussed, or 
to the number of portions into which the daily quota is sub- 
divided and ingested, in other words, the number of meals per 
day. Ingested protein is rapidly metaboHzed and there is 
little storage of protein or amino-acids in cornparison to the 
reserves of fat and carbohydrate in the body. If the protein 
required for one day be ingested at one time a large proportion 
of it will be utiHzed or deaminized in from six to nine hours, 
and to satisfy the needs of the actively functioning tissues the 
body will draw upon its own protein reserves. By taking the 
protein in smaller quantities a number of times a day the body 
will be more continuously supplied with the necessary amino- 
acids derived from its digestion. A similar effect can be pro- 
duced in part by mixing the protein with more or less indi- 
gestible material which apparently delays the digestion and 
absorption of protein. Nitrogen equilibrium has been main- 
tained upon a diet low in protein when ingested in six equal 
portions which was not sufficient when ingested in three 
portions. 

The following studies by Thomas of the relative efficiency 
of protein in the maintenance of nitrogen equihbrium illus- 
trate the variable usefulness of different proteins. The basis 
of valuation of the food proteins is such that lOO represents 
protein which satisfies the basal requirement determined on 
a protein-free diet when fed in equivalent quantities — with 
ample quantities of carbohydrate and fat. 



Biological Value of Proteins. 

Meat 104 

Milk 99 

Fish 94 

Rice 88 

Potato 78 

Bean ^ . . . . 55 

Flour (wheat) " . . . . 39 

Corn 29 



72 PROTEIN REQUIREMENT 

The high efficiency of meat protein has been ascribed by 
Thomas as due to the effect of extractives which may be con- 
cerned in the maintenance of nitrogen equihbrium. This is 
only one possibiHty for we know Httle of the relative structures 
and combination of proteins in different foods or of associated 
factors, all of which might be effective. It is certainly true 
that animal proteins in general are more efficient in the human 
economy than vegetable proteins. 

Our discussion has confined itself more or less to partic- 
ular proteins. In the average diet a mixture of proteins is 
ingested so that the sum total is entirely sufficient for the 
needs of the body. In meat insufficient gelatin (collagen) 
occurs with the eminently satisfactory muscle protein, and 
likewise in corn the incomplete zein is associated with other 
proteins which contain the requisite amino-acids. 

The protein requirement is influenced by the quantity of 
fat and carbohydrate, energy-yielding foods, present in the 
diet. The effect of these food-stuffs is to lower or raise the 
plane of protein metabolism when added or subtracted from 
a nitrogenous diet; fat is, however, less effective than carbo- 
hydrate. If the carbohydrates of a mixed diet, upon which 
nitrogen equilibrium is being maintained, be replaced by an 
isodynamic quantity of fat, a negative nitrogen balance will 
result; that is, the body will use some of its protein reserve. 
The replacement of fat by carbohydrate is accompanied by a 
lowered protein utilization. This is particularly true when the 
protein ingestion is low. When carbohydrates are fed to a 
fasting man or dog, or to one who is receiving a carbohydrate- 
free diet, either with or without protein, the rate of nitrogen 
excretion is lowered. Fat also is capable of reducing the plane 
of nitrogen metabolism of a fasting organism, particularly 
when the subject is poor in fat. Variations of fat and carbo- 
hydrates within certain limits when both appear in the diet 
at the same time do not result in marked variations in the 
protein metabolism. It may be that the failure of fat to main- 
tain nitrogen equilibrium when it replaces carbohydrates is due 
to the fact that the body requires a certain amount of carbo- 
hydrate for its normal functioning and, that since fat apparently 
does not yield carbohydrate, and the amino-acids of the pro- 
tein molecule may do so, the body breaks down an additional 
quantity of protein to furnish the necessary carbohydrate. 
Thomas has suggested that the beneficial effect of carbohy- 
drate is concerned with the synthesis of amino-acid in the body. 

Lusk has suggested that lo to 15 per cent, of the total 
energy requirement be in the form of protein. For the aver- 
age protein requirement of man see the following discussion of 
standard dietaries: 



STANDARD DIETARIES 73 

STANDARD DIETARIES— AVERAGE PROTEIN 
REQUIREMENT. 

Practically all the standard dietaries which have been pro- 
posed have been determined by the statistical method. 
Observations have been made of the quantity and kind of 
food ingested b}^ a large number of persons under different 
circumstances; the composition of various kinds of food has 
been determined; on the assumption that the results of these 
analyses approximate the composition of the food eaten in the 
dietary investigated, the amounts of protein, fat, and carbo- 
hydrate in the diet have been determined. Voit's standard 
was the first to attract widespread attention and it has been 
the nucleus of controversy concerning the optimum protein 
requirement for man. Voit proposed for a man at moderate 
work : 

Protein ii8 grams. 

Fat 56 " 

Carbohydrate 500 " 

Total Calories 3055 

Investigations of the dietary habits of groups of people in 
various countries and conditions have been the basis of other 
dietary standards. The following table contains some of the 
standards which have been suggested: 

Standard Dietaries. 





Protein, 


Fat, 


Carbohydrate, 


Fuel value 


Author and conditions. 


gm. 


gm. 


gm. 


Calories. 


Atwater (man): 










Hard work 


. 150 


. . 




4150 


Moderate work . 


• 125 






3400 


Sedentary life 


100 






2700 


Rest (or woman at 


ight 








work) . 


. . 90 






2450 


Voit (Germany): 










Average diet . 


. . 1x8 


56 


500 


3053 


Hard work 


• • 145 


100 


450 


3300 


Playfair (England) 


. 119 


51 


531 


3060 


Gautier (France) . 


. . 107 


65 


407 


2630 


Chittenden . 


. . 60 






2800 



From this table we see that the quantity of food in the form 
of protein, fat and carbohydrate varies with the kind and 
degree of work performed; the amount of food required varies 
also with the age, and with the sex of the individual. 

The influence of work upon the energy and protein require- 
ments has been discussed in general. A greater consumption 
of energy-yielding material is required to satisfy the needs of 
a man at work than is required by a person at rest. This 



74 PROTEIN REQUIREMENT 

fact has been established by careful experiments in confirma- 
tion of the results obtained by dietary studies. 

External temperature also modifies energy requirements. 
A man exposed to the cold requires a greater quantity of energy- 
yielding food than the one who does the same work at a 
moderate temperature. For this reason studies of the daily 
habits of people of different climates show the ingestion of diets 
of different energy contents. Differences in the size and age of 
individuals involve diets of different energy content. The 
infant has a higher energy metabolism than an adult in the 
prime of life; and an old man, a smaller requirement. Two 
adults of the same size and weight, performing the same work, 
require approximately the same amount of energy. But where 
there is a difference of size, as in the case of a lean man and a 
fat man of the same weight, and approximately the same body 
surface, the energy requirement of the thin man is much higher 
because of the greater mass of functioning tissue. 

To these physiological factors, which influence the energy 
requirement of man, the psychical and economic factors must 
be added. Such considerations as taste, habit and custom, 
the kind of food available, and the abihty to purchase, modify 
the quantity and kind of food eaten by any given group of 
individuals. Hence the standards based upon the study of 
the food consumption of various classes and races of people 
reveal not only the actual needs but also the habits and pro- 
pensities of the people. 

When considering the basal protein requirement of man we 
found that muscular activity had practically no effect upon 
the protein metabolism. An examination of the table con- 
taining the proposed standard diets of various investigators 
shows an increase in the quantity of protein where the fat and 
carbohydrate have been increased to meet the changed energy 
requirements. The studies on which these standards are 
based apply to men of different physique and muscular devel- 
opment, which difference is in itself reason for different amounts 
of protein in the diets. When it is considered, however, that 
the protein requirement of a man at moderate labor is already 
greatly in excess of his basal requirements, it is diflftcult to 
understand the reason for large increases in the protein portion 
of the diet of individuals at hard labor whose muscular develop- 
ment probably is not greatly increased. 

The increased production of heat (specific dynamic action) 
following the ingestion of protein, with the accompanying 
feeling of warmth is a partial explanation of the desirability 
of an increased protein ingestion by those exposed to cold; and, 
conversely, of the undesirability of a high protein diet in the 



STANDARD DIETARIES 75 

tropical climates. The heat derived from such action of 
protein has been shown to be available for the maintenance 
of body temperature, but not for work. 

The optimum protein requirement of man has been a sub- 
ject of considerable controversy. The discussion concerns 
chiefly the standards which we have already discussed — 
approximately loo to 150 grams of protein per day — and an 
amount considerably less than this, 50 to 75 grams of protein 
per day. On the one hand there is the evidence of the amount 
of protein which various peoples have been in the habit of 
eating and apparently crave. On the other hand there is a 
physiological basis for a low protein diet in that the minimal 
requirements of the average man are much lower than 100 
grams of protein per day, that the body can satisfy its energy 
requirements with fats and carbohydrate and that the protein 
material taken in excess of the body needs is decomposed, 
and the nitrogen portion is excreted in the kidneys chiefly in 
the form of urea, while the carbon moiety is utilized for the 
production of energy. Chittenden has been the chief advo- 
cate of the low protein diet. Hindhede, from his work on the 
use of the potato as the chief article in the diet, has recently 
advocated an even lower diet than that of Chittenden. 

Various arguments have been advanced for and against a 
low protein diet. Those who believe that such a diet is advis- 
able base their opinion, in addition to the facts indicated 
above, on observations which indicate that such a diet results 
in greater strength and endurance, is more economical, and in 
accompanied by a lowered intestinal putrefaction. Against a 
low protein diet arguments have been presented to the effect 
that men do not eat a low protein diet from choice, that there 
is the danger of the selection of a diet with a low total caloric 
value, that the *' minimum is not necessarily the optimum," 
and that low planes of mental, moral and physical develop- 
ment exist in countries in which the population subsist on a 
low protein plane. One of the most telling arguments in favor 
of a high protein diet, where the nature of the protein and the 
qualitative nature of the diet is not known, is the finding of 
McCuUom that an increase of the protein portion of a diet 
will in certain cases overcome the effect of toxic substances 
present in food (p. 98). 

The values for the average protein requirement given m the 
table on page 73 have been determined chiefly by statistical 
means. The protein requirement is apparently not affected 
by as many variables as the energy requirement. Muscular 
work does not materially affect the protein metabolism 
provided the increased energy requirements are met with 



76 PROTEIN REQUIREMENT 

sufficient quantities of non-nitrogenous food-stuffs: fat and 
carbohydrates. When the body is already meeting a part of 
its energy requirements with protein material, such as might 
exist in underfeeding or in fasting, increased activity is asso- 
ciated with an increased protein destruction. There might in 
the course of time be an indirect increase in the protein metab- 
olism following work as a result of an increase in the quantity 
of muscular tissue with its greater *'wear and tear." 

The protein requirement varies with the age of the indi- 
vidual considered. An infant, which is forming new protein 
as well as repairing the wear and tear of its body, requires 
proportionately more protein than does an adult who needs 
only to supply the protein for repair. An old man, with rela- 
tively diminished muscular development and tone, requires less 
protein material than the adult who is in the prime of his 
life. Muscular development undoubtedly affects the amount 
of nitrogenous material required; while the protein needs of 
the pregnant woman or nursing mother are increased because 
of the storage of nitrogenous material in pregnancy, and the 
drain upon the stored protem experienced during lactation. 
Although the average diet contains sufficient protein material 
to cover any variations m the requirements due to size, age, 
and sex, these factors must be considered when an insuffi- 
cient or a restricted diet is prescribed. 



CHAPTER IV. 
INORGANIC SALTS AND WATER. 

The importance of inorganic salts has not been emphasized 
in dietetics so much as the energy and protein parts of the diet. 
That this is so has been due in part to the fact that the aver- 
age mixed diet contains a sufficient amount of the various 
inorganic constituents for all general purposes. Studies of 
pathological conditions, however, have repeatedly demon- 
strated that a diet may be entirely satisfactory from the 
stand-point of protein and energy and still be lacking in some 
inorganic constituent, or group of constituents, which, when 
supplied, rectified the trouble. 

A consideration of the role played by inorganic substances 
in nutrition will serve to bring out their importance in the 
dietary. Whereas fat, protein, and carbohydrate serve to fur- 
nish energy to the body, inorganic salts are not concerned 
directly with this. In their capacity, however, of regulating 
the body functions they contribute toward the oxidation of 
these various food substances. Iron in particular appears to 
be concerned in oxidation. We find this element in the red 
blood corpuscles as an important and apparently active con- 
stituent of the hemoglobin. Certain investigators have 
attempted to show that the action of oxidases is due to the 
inorganic elements or salts which are contained in them. 

The fluids and tissues of the body are maintained in osmotic 
equilibrium by the contained salts. The accumulation of 
water in one portion of the body or the desiccation in another 
is prevented by the diff'usibihty of salts or the attraction for 
water when separated from the surrounding medium by a 
semipermeable membrane. When there is a perversion of 
this property by a change in the physical structures or the 
chemical properties we find pathogenic states to exist, such, 
for instance as the condition of edema. 

The inorganic elements occur in the body in two general 
forms: (a) Combined with organic material as such, as radicles 
or held in an insoluble form such as the iron of hemoglobin, 
the phosphorus of nucleoprotein, the iodine of the thyroid 
gland, and the constituents of the structural tissue and of all 
actively functioning tissues, e. g., the calcium and magnesium 



78 INORGANIC SALTS AND WATER 

and phosphorus of the bone; {h) in solution as ionizable salts 
where they are active in maintaining osmotic equiHbrium, and 
the constant reaction of the body fluids, assisting in the trans- 
portation of the oxygen and carbon dioxide in the blood, 
concerned in the permeability of the cell walls, and affecting 
the irritability of muscle and nerve. 

The mere enumeration of a few of the important uses of 
the inorganic elements brings out strikingly their significance. 
The multiplicity of their function has likewise rendered the 
study of these substances difficult, for with one element having 
a varied function, its removal from the diet may be respon- 
sible for many secondary reactions which will mask the direct 
result. 

Experiments designed to show the effect of the complete 
removal of salts have demonstrated that an ash-free diet is 
detrimental to the organism. It was early shown that a diet 
containing the requisite amount of carbohydrate, fat, and .pro- 
teid but which did not contain the ash constituents resulted, 
in an early death. Von Bunge suggested that these harmful 
effects were due largely to an excess of acidic radicles present 
in the body caused by the sulphuric acid formed in the pro- 
cess of metabolism from the sulphur present in the protein 
molecule. Ordinarily this acid would be neutralized by the 
fixed bases present in the diet. In the absence of these, how- 
ever, they derive a certain portion of their required base 
from the alkali radicles in the tissues. He suggested the 
addition of carbonates to combat this acidity. 

Studies of the effect of an ash-free diet upon man have been 
made. In one case symptoms were experienced which were 
analogous to that associated with acidosis, including muscular 
weakness and the presence of acetone on the breath. Other 
investigators failed to obtain any symptoms of acidosis. In 
both experiments there was a loss of weight as the result of 
the ingestion of an ash-free diet. It is apparent that individual 
differences must be considered in the interpretation of such 
data. 

The analyses of various foods for the inorganic elements 
they contain, and a consideration of the latter on the basis 
of whether they yield an ash which is predominantly acidic 
or basic in nature, have shown that some foods, upon oxida- 
tion in the body yield an excess of acidic over the basic 
elements, while of others the opposite is true. An excess of 
inorganic acid radicles in the blood, whether they occur as the 
result of the ingestion of the acids themselves or are produced 
in the processes of metaboHsm from neutral compounds, is 
neutralized in one of two ways — by combination {a) with 



INORGANIC SALTS AND WATER 



79 



ammonia or {b) with some of the fixed alkalis of the body. 
Since there is at all times an equilibrium, both changes occur. 
Such changes produce an excess of salts in the blood which is 
excreted in the urine. The fixed bases which accompHsh this 
neutrahzation may come from the alkaline carbonates of the 
blood, perhaps from the calcium or magnesium of the bones. 
The ultimate result, if the diet be continued, is the reduction 
of the body's store of basic elements. Such a condition we 
have already considered in our discussion of the effect of a 
salt-free diet. The effect of an excess of basic elements in the 
body is not so serious, for they may be neutralized by the 
carbonic acid formed in the process of oxidation. The urine 
excreted after the ingestion of a diet which contains an excess 
of potential basic ash constituents will tend to be alkaline, 
while that obtained after a potentially acid diet will be acid. 
Sherman and Gettler have recently considered some of the 
more important foods on the basis of their acid- or base- 
yielding properties, and have called attention to the desir- 
abiUty of balancing potentially acid foods in the diet with 
predominantly base-yielding foods. The accompanying table 
gives the result of their work, grouped according to predomi- 
nating acid- or base-yielding power. 

Excess Acid or Base in Representative Foods in Terms 
OF Normal Solutions.^ 



• Article of food. 

Succulent vegetables: 

Asparagus . 

Potatoes 

Carrots (or beets) . 
Fruit: 

Cranberries . 

Pineapple 
Nuts: 

Almonds 

Walnuts . . . . 
Legumes . . . . 
Cereal : 

Oatmeal (or wheat) 

Rice 

Lean meat . . . . 

Fish 

Milk 

Cheese 

Eggs 



Potential acid. 
Per 100 Per 100 

em. calories. 



Potential base. 
Per 100 Per 100 



12.9 

7.8 
12.0 

7.8 



HI 



3-2 

2-5 

10.4 



I .2 

7-5 



gm 
O 

7 
10 

I 
6 



23 



calories. 

3-6 

8.6 

237 

3-8 
157 

1.8 
6.9 



2.6 



It will be seen in general that, with the exception of milk, 
animal products yield an excess of acid radicles and the same 

* Compiled from Sherman: Food Products, 191 5. Sherman and Gettler: Jour. 
Biol. Chem., 1912, xi, 363. 



80 INORGANIC SALTS AND WATER 

may be said of the cereals. Vegetables and fruits are chiefly 
base-yielding foods. That foods which are rich in the salts of 
organic acids should yield an excess of base is due to the fact 
that the acid portion of the molecule is oxidized in the body 
yielding carbonates which are potentially basic. 

Calcium, phosphorus, potassium, sulphur, sodium, lithium, 
chlorine, magnesium, manganese, iron, boron, iodine, fluorine 
and siHcon are the more important "mineral " elements found 
in the body. The bases are combined chiefly as phosphates, 
sulphates, chlorides, and carbonates. Of the chlorides in the 
body the sodium salt predominates. It is the most abundant 
inorganic constituent of the diet and also of the urine. The 
fluids of the body are particularly rich in sodium salts and, 
consequently, in sodium chloride; while the potassium salts 
predominate in the tissues, chiefly as the phosphates. The 
quantity of chlorides in the urine is directly related to that 
ingested, for the body tends to maintain itself in chlorine 
equilibrium. 



CHLORINE REQUIREMENT OF MAN. 

The sodium chloride requirement of the body is difl&cult to 
determine. Studies of the minimum chloride requirement in 
which there is a complete removal of salt, as in fasting or an 
ash-free diet or sodium chloride-poor diet, fail to determine 
the optimum requirement; they always show the lowest excre- 
tion under conditions in which the body has lost its reserve 
and is tending to conserve that amount which is left. Such 
studies on man indicate a loss of approximately lo to 12 grams 
of sodium chloride, calculated as chlorine, in the course of ten 
days. The daily excretion decreases gradually until it reaches 
a low level when between o.i and 0.2 gram of chlorine are 
excreted per day. That, in such cases, chlorides have been lost 
beyond the reserve that is related to the quantity of chlorine 
ingested (which results in part from a lag in its excretion) is 
evidenced by the marked retention of chloride during the first 
days of feeding after a fast or the ingestion of a salt-free 
diet. 

The sodium chloride requirement is aff'ected by the nature 
of the diet. This is brought out most strikingly by a consid- 
eration of the quantity of sodium chloride taken by the her- 
bivora as contrasted with the carnivora. Von Bunge was the 
first to call attention to the fact that the carnivora do not exhibit 
the marked craving for salt that is evidenced by the herbivora. 
He ascribed this difference to the greater quantity of potassium 
salts ingested with a vegetable diet, which caused an increased 



CHLORINE REQUIREMENT OF MAN 



81 



Chlorine Content of Foods. 

Per cent. Chlorine in 

of edible 100 -Calorie 

portion. portion, gm. 

Protein-rich foods : 

Cheese i.o 0.2 

Chicken 0.6 0.02 

Beef and veal 0.5 o . 05 

Cheese, cottage 0.5 

Fish: 

Salmon 0.28 0.13 

Cod, haddock 0.24 0.33 

Egg white 0.15 0.28 

Milk, whole 0.12 0.17 

Milk, butter o. 10 0.275 

Egg, whole o.io 0.06 

Egg, yolk 0.10 0.03 

Lentils 0.08 0.02 

Peanuts 004, 0.007 

Peas, dried 0.04' o.oi 

Beans, dried 0.03 0.008 

Walnuts o.oi o.ooi 

Carbohydrate-rich foods : 

Potatoes 0.12 o.io 

Flour, wheat 0.07 0.02 

Commeal 0.06 0.02 

Rice 0.05 o.oi 

Oatmeal 0.035 0.009 

Potato, white 0.03 0.04 

Barley, pearled 0.02 0.005 

Rye 0.02 0.005 

Honey o.oi o.oi 

Sugar 

Water- and salt-rich foods: 

Celery 0.17 0.9 

Lettuce 0.06 0.3 

Cauliflower 0.05 0.16 

Radish 0.05 o. 17 

Beets 0.04 0.08 

Carrots 0.036 0.078 

Rhubarb 0.035 0.15 

Cabbage 0.03 0.09 

Tomatoes 0.03 0.09 

Spinach 0.02 0.08 

Com, green 0.014 0-.014 

Cherries o.oi o.oi 

Grapefruit o.oi 

Grapes o.oi o.oi 

Lemons o.oi 0.02 

Oranges o.oi 0.02 

Peaches o.oi 0.02 

Peas, green o.oi o.oi 

Squash o.oi 0.02 

Beans, green 0.009 0.007 

Apples 0.004 0.006 



Weis<ht of 
lOO-Calorie 
portion, gm. 

23 
45-93 
35-50 

31 

70 
216 
196 

145 

280 

68 
28 
29 
18 
28 
29 
14 



81 
28 
28 
29 

25 
120 
28 
28 
31 



540 
524 

328 

341 
217 
221 

433 
317 
439 
418 

99 

128 

104 

226 

195 
242 
100 
217 
82 
159 



Fat-rich foods: 

Butter; lard; olive oil; salt pork; bacon; salt content, high and varies. 

6 



82 INORGANIC SALTS AND WATER 

excretion of potassium chloride, with the consequent deple- 
tion in chlorine. That potassium salts do cause an increased 
chlorine excretion has been shown by direct experimentation. 
From these considerations it is evident that the estimation of 
the quantity of sodium chloride required per day is a difficult 
matter. The quantity of chlorine necessary to protect the 
body against loss of chlorine has been placed at 3 or 4 grams 
per day. The average consumption has been estimated at 
from 15 to 20 grams of sodium chloride per day. 

Ingestion of large quantities of sodium chloride increases the 
excretion of nitrogen. The explanation of this is not clear; it 
seems probable that it is due to the accompanying diuresis. 

The table on page 81 gives the average chlorine content of 
various foods arranged (i) according to whether they are 
particularly valuable as sources of protein, carbohydrate, or 
for the salts and water which they contain and (2) in each 
group in the order of their decreasing chlorine content. 

PHOSPHORUS REQUIREMENT OF MAN. 

Phosphorus^ occurs abundantly in the body almost exclu- 
sively in the oxidized form as the phosphoric acid radicle. As 
such, however, it appears in a variety of combinations. Thus 
it occurs in the body or in the combined form with the protein 
molecule as nucleoprotein of the cell nuclei and as the phospho- 
proteins casein and vitelHn; combined with fatty acids as 
lecithoprotein, the lecithins, and the phosphatides of the 
nervous tissue; in simple organic combination in the plant 
as phytin, and finally in the inorganic state combined with the 
various bases in the skeleton, particularly with calcium and 
magnesium and in the body in general as the sodium and 
potassium salts. 

As a constituent of the nuclei the phosphoric acid takes part 
in one of the most vital processes of the body, the formation 
of new cells. Combined with calcium and magnesium it 
becomes the constituent which gives permanence and hard- 
ness to the bones, while as a soluble salt dissolved in the 
fluids of the body in conjunction with the carbonates and 
proteins it serves to maintain the neutrality of the tissues. 

The question of the ability of organic and inorganic phos- 
phorus to supply the body needs has been one which has 
received a great deal of attention. This problem is particu- 
larly important in connection with the artificial feeding of 

^ For a review of the metabolism of phosphorus the reader is referred to the 
excellent and complete review of the literature on this subject by Forbes and 
Keith: Ohio Agric. Exp. Sta., Tech. Bull. No. 5, 1914. 



PHOSPHORUS REQUIREMENT OF MAN 83 

infants and the treatment of disease. The weight of the evi- 
dence shows that only a small amount of organically combined 
phosphorus is necessary in the diet provided a sufficient 
amount of inorganic phosphorus is present. Forbes has recently 
summed up the evidence with regard to the availability of 
organic and inorganic phosphorus. In his review of the fac- 
tors which might affect the correct interpretation of the data 
considered — in which he calls attention to the fact, the impor- 
tance of which has become daily more evident, that it is 
necessary to consider the presence or absence from the exper- 
imental diet of such substances as the "vitamines" or lipoids 
(see p. 94) before we shall be able to demonstrate conclusively 
the greater advantage of one form of phosphate over the 
others or their equality. Forbes concludes with the following 
statement: 

"It therefore seems not at all unlikely that the many demon- 
strations of the superior nutritive value of organic phosphorus 
compounds have been influenced by other beneficial sub- 
stances occurring in association with them in natural foods, 
and contained as impurities in these organic phosphorus 
compounds as isolated and used in nutrition investigations. 
As to the relative importance of this factor and others we are 
as yet unprepared to make positive assertions; but these 
recent studies at least raise the question as to whether the 
apparent superiority of organic to inorganic phosphorus com- 
pounds is due to these organic compounds by themselves, or 
whether their superiority is dependent upon minute quanti- 
ties of certain associated compounds. However this question 
may be settled the studies, certainly suggest that, if the natural 
organic phosphorus compounds are not of superior usefulness, 
or are not essential to the maintenance of growth in animals, 
then other nutrients associated with them in the natural foods 
are essential, and the result therefore is to put a new emphasis 
on the value of the natural organic food-stuffs as compared 
with inorganic or artificially synthetized nutrients and certain 
manufactured foods." 

The phosphorus requirement of man has not been deter- 
mined with any certainty. The procedure is difficult because, 
unlike many of the products of metabolism, a large propor- 
tion of the phosphorus may be excreted in the feces. The 
daily requirement of the adult man has been placed at 1.5 
grams of phosphorus (P) or 3.5 grams of P2O5. Under 
special conditions the requirement may be as low as 0.9 gram 
P or 2 grams of P20r,. 

The quantity of food phosphorus that may be retained 
depends upon the nature of the diet. Since a large proportion 



84 INORGANIC SALTS AND WATER 

Phosphorus (P2O5) Content of Foods (Average Daily Requirement 

2.75 Grams). 

Per cent. P2OS in Weight of 

of edible 100-Calorie lOO-Calorie 

portion. portion, gm. portion, gni. 

Protein-rich foods: 

Cheese, hard i . 45 0-39 23 

Beans, dried 1.14 0.326 29 

Egg, yolk i.o 0.27 28 

Peas, dried 0.91 0.24 28 

Peanuts 0.90 0.16 18 

Beans, lima, dried .... 0.77 0.22 29 

Walnuts ^"n o.ii 14 

Lentils 0.66 0.29 29 

Cheese, cottage 0.50 0.40 31 

Meat and chicken . . . . 0.50/ ^f ^t) o.i 5-0 • 1 8 45-93 

^ \(lean) 0.24-0.30 . . - 

Fish 0.40 ' 0.60 50 

Egg, whole 0.37 0.24 68 

Milk, whole 0.22 0.303 145 

Milk, skimmed 0.22 0.60 273 

Egg, white 0.03 0.05 196 

Carbohydrate-rich foods: 

Oatmeal, dry 0.827 0.216 25 

Barley, pearled 0.46 0.127 28 

Bread, whole wheat .... 0.40 0.16 39 

Cornmeal 0.30 0.08 28 

Potato, white 0.14 0.166 81 

Rice 0.203 0057 29 

Bread, white 0.20 075 39 

Wheat flour 0.20 0.05 28 

Potato, sweet 0.09 0.08 loi 

Water- and salt-rich foods: 

Wheat bran 3.0 

Almond 0.87 0.132 15 

Beans, green 0.27 0.22 82 

Peas, green 0.26 0.24 100 

Corn, green 0.22 0.21 99 

Cauliflower 0.14 0.45 328 

Spinach 0.13 0.54 418 

Beans, string ...... 0.12 0.28 241 

Carrots o.io 0.22 221 

Celery o.io 0.54 540 

Lettuce 0.09 0.47 524 

Asparagus 0.09 0.39 450 

Cabbage 0.09 0.28 317 

Beets 0.09 0.19 217 

Squash 0.08 0.08 217 

Cherries 0.07 0.09 128 

Tomatoes . 0.059 0.257 439 

Oranges 0.05 0.09 195 

Peaches 0.047 o.ii 242 

Apples 0.03 0.05 159 

Lemons o.oi 0.04 226 

Fat-rich foods: 

Cocoa I.I 0.22 20 

Chocolate 0.90 0.14 16 

Cream 0.18 o.io 51 

Butter 0.03 0.004 13 



CALCIUM REQUIREMENT OF MAN 85 

is deposited in the bones, the presence of a sufficient amount 
of the bases, calcium and magnesium, associated with it in 
such structures is essential. When these are not present the 
phosphoric acid radicle is excreted in combination with the 
more soluble bases and thus fails to satisfy the requirements. 
The ingestion or formatiofi of acids or acid-yielding substances 
results in an increased excretion of phosphorus. 

The phosphorus of the food, obtained as it is from both the 
animal and vegetable kingdom occurs in a variety of organic 
compounds, the particular advantage of any one of which has 
not been determined. Feeding experiments in which one type 
of phosphorus is fed to the exclusion of all others do not neces- 
sarily demonstrate the true availability of the compound. In 
selecting diets, then, for their phosphorus content we cannot lay 
stress on any given food as presenting the constituents in a more 
available form than another. In considering data with regard 
to the P2O5 content of foods and particularly the vegetables, 
it is to be remembered that in their preparation a certain pro- 
portion of the phosphorus is removed. This is particularly 
true in the removal of the outer coating of cereals. 

The table on page 84 gives the relative quantity of 
P2O5 in some of the more common foods. 



CALCIUM REQUIREMENT OF MAN. 

Calcium salts play a varied role in the body economy. Cal- 
cium occurs in the bones chiefly as phosphate. Dissolved in the 
body fluids calcium is an important factor in the coagulation 
of the blood and in the contraction of the muscles. Underbill 
has suggested that calcium salts play an important role in the 
regulation of the blood-sugar content. 

During the period of growth the importance of calcium salts 
is most easily demonstrated, for at this time the body is utiHzing 
relatively large quantities of calcium, the removal of which 
from the diet at this time results in arrested or poor develop- 
ment of the bones. It is for this reason that consideration of 
the calcium requirement of the growing child is very impor- 
tant. The disease most commonly associated with calcium 
metabolism, rickets, may not be entirely the result of a lack 
of calcium in the diet but of a failure to assimilate it. In the 
adult the temporary removal of calcium is not followed by 
such marked effects as those observed in growth, for the body 
can call upon its reserve for a considerable time without 
showing any undesirable effect. Calcium, like phosphorus, 
is excreted largely through the intestine, and its excretion is 
continued in fasting. 



86 INORGANIC SALTS AND WATER 

The importance of calcium and the fact that it is impos- 
sible to consider each salt by itself is well illustrated in the 
use of such solutions as Ringer solution and the antagonistic 
action of salts. Physiological salt solution is sufficient to 
maintain the osmotic properties of muscle. In such a solu- 
tion, however, muscle will not exhibit its properties of irrita- 
bility and contractibility for any length of time. If, to the 
physiological salt solution, calcium and potassium chloride 
be added in the proper proportions, it will exhibit these prop- 
erties for a much longer period; aw isolated heart when sup- 
plied with oxygen will continue to beat spontaneously for a 
long time in Ringer solution which contains these salts. An 
excess of calcium may produce a condition of tonic contraction 
called "calcium rigor." Lceb has recently shown that the 
ions antagonize each other in their effect upon body processes; 
particularly the permeability of cell membranes. Membranes 
such as those surrounding sea-urchin eggs are permeable to 
certain concentrations of sodium chloride and dilute acids. 
If to such solutions a bivalent ion, such as calcium or mag- 
nesium, be added the permeability is greatly reduced. Clowes 
has been able to produce results analogous to these in purely 
physical systems. Thus we see that the role of salts in the 
body, aside from their structural value, is very complex. 

In discussing the cathartic action of salts Meltzer calls 
attention to the fact that the salts of magnesium are essen- 
tially inhibitors of intestinal movement and suggests that the 
purgative effect produced by such salts is the result of the 
combined action of sodium salts which stimulate contraction 
and of magnesium salts which cause a relaxation. This 
inhibitory effect of magnesium, which extends to other parts 
of the body, may be counteracted by subsequent injections 
of calcium salts. Anesthesia has been produced by the injec- 
tion of magnesium sulphate. 

The calcium requirement of man varies with the period of 
life. The growing child requires a greater proportionate quan- 
tity of calcium per day than an adult in middle life; while an 
old man requires much less. Dietary studies show that an 
ingestion of approximately 0.7 gram of calcium (calculated as 
oxide) per day is the smallest amount which will maintain the 
average normal adult in calcium equilibrium on an ordinary 
diet. Since absorption is not always complete, a somewhat 
larger quantity is desirable, i to 1.5 grams per day. 

Whether or not the average mixed diet satisfies the calcium 
requirement without special selection of food is a matter 
which is open to question. When the food consists chiefly of 
meat and cereals, foods low in calcium, it is probable that the 



CALCIUM REQUIREMENT OF MAN 



87 



Calcium (CaO) Content of Foods (Average Daily Requirement 

0.7 Gram). 

Per cent. CaO in Weight of 

of edible 100-Calorie 100-Calorie 

portion. portion, gm. portion, gm. 

Protein- rich foods: 
Cheese : 

Hard ....... i.i 0.25 23 

Cottage ' . 0.3 0.30 31 

Beans, dried 0.22 0.063 29 

Egg, yolk 0.20 0.05 28 

Milk, whole 0.168 0.24 145 

Milk, skimmed 0465 273 

Buttermilk 0.15 0.415 280 

Peanuts 0.14 0.04 18 

Lentils 0.12 0.04 29 

Walnuts o.ii .. 14 

Beans, lima, dried . . . .0.10 0.028 29 

Egg, whole 0.093 0.06 68 

Egg, white 0.015 0.028 196 

Fish 0.015-0.08 0.033 50 

Meat 0.01-0.03 0.005-0.01 45-93 

Carbohydrate-rich foods: 

Oatmeal 0.13 0.03 25 

Wheat 0.06 0.01 27 

Bread, whole wheat . . .0.04 0.016 39 

Bread, white 0.03 o.oii 39 

Barley, pearl 0.025 0.007 28 

Potato, sweet 0.025 0.02 loi 

Wheat flour 0.025 0.007 28 

Potato, white 0.016 0.019 ^i 

Commeal . 0.015 0.004 28 

Rice 0.012 0.003 29 

Honey 0.005 o.ooi 

Sugar 

Starch 

Water- and salt-rich foods: 

Almonds 0.30 0.046 15 

Cauliflower 0.17 0.55 328 

Olives 0.17 o . 06 40 

Celery o.io 0.54 540 

Dates 0.10 0.03 29 

Spinach 0.09 0.37 418 

Beans, string 0.075 0.177 241 

Carrots 0.077 0.168 221 

Oranges 0.06 o.,ii 195 

Rhubarb 0.06 0.26 433 

Lemons 0.05 0.12 226 

Lettuce .0.05 0.26 524 

Radish 0.05 0.17 341 

Asparagus o . 04 0.17 450 

Beans, lima 0.04 0.033 82 

Peas, green 0.04 0.032 100 

Beets 0.03 0.06 217 

Cherries 0.03 0.04 128 

Squash 0.02 0.054 217 

Tomato 0.02 0.087 439 

Prunes (dried) o . 02 . . 33 

Apples 0.014 0.022 159 

Fat-rich foods: 

Cocoa 0.14 0.027 20 

Chocolate 0.14 0.052 16 



88 INORGANIC SALTS AND WATER 

calcium ingestion is not sufficient. If the diet contains milk, 
eggs (yolk), legumes, and fruits the diet will probably contain 
a sufficient quantity of calcium. 

The diet of pregnant and nursing mothers and children 
requires special consideration. During pregnancy and lacta- 
tion the mother is nourishing the young through her own 
system. At this time, too, there is an especial necessity for 
calcium and the other constituents which are concerned in the 
structural tissues of the body — magnesium, iron, and phos- 
phorus. Forbes has recently shown that the cow when pro- 
ducing milk apparently draws upon her own calcium reserve, 
even though there be ample supplies of calcium in the diet. 
It is essential, then, that the mother have a plentiful supply 
of those foods which furnish these inorganic elements. Decay 
of teeth during pregnancy, has been ascribed to the drain 
upon the calcium reserves caused by the secretion of milk. 

The nature of the diet of a child is also important after it 
has ceased to depend upon its mother for food. Particular 
attention should be given to the calcium content of the food, 
for here the diet changes from one consisting of milk, which 
is richest in calcium, to a mixed diet which, unless properly 
chosen, may be poor in calcium. A calcium deficit for a grow- 
ing child results in soft bones with the resulting abnormalities 
of structure. 

The table on page 87 contains the more common foods grouped 
according to calcium content. 

IRON REQUIREMENT OF MAN. 

Iron occurs as a constituent of the blood pigment. We find 
it also in the chromatin of cells in which it is in part concerned, 
with the processes of oxidation, not only as a carrier of oxy- 
gen but as a catalyzer of enzyme action. The total quantity 
of iron in the body has been estimated at from 3 to 4 grams. 

The iron requirement of man has been estimated at from 
o.oi to 0.012 gram of iron per day. Until a more careful 
determination of the actual requirements has been established 
a slightly higher value of 0.015 gram per day has been sug- 
gested (Sherman). Women require much more iron than 
men. During the periods of pregnancy, lactation and men- 
struation of women there is a considerable loss of iron which 
must be replenished and in the growth period of children there 
is a greater demand for iron than in the adult. Observation 
has shown that the body is proportionately richer in iron at 
the time of birth than at any other time in its development. 
Analyses of milk and of the newborn and young have shown 



IRON REQUIREMENT OF MAN 



89 



Iron (Fe) Content of Foods (Average Daily Requirement 0.015 Gram), 



Per cent, of 
edible portion. 
Protein-rich foods: 

Lentils 0.0086 

Egg, yolk o . 0085 

Beans, dried 0.007 

Beans, lima, dried . . . 0.007 

Peas, dried 0.0056 

Fish 0.004 

Meat 0.0038 

Egg, whole 0.003 

Walnuts 0.0021 

Chicken 0.002 

Peanuts 0.002 

Milk, skimmed .... 

Milk, whole 0.00024 

Egg, white o.oooi 

Carbohydrate-rich foods: 

Wheat 0.0053 

Oatmeal, dry .... 0.0036 

Bread, whole wheat . . . 0.0015 

Wheat, flour 0.0015 

Barley, pearled .... 0.0013 

Potato, white . . . . 0.0013 

Commeal o.ooii 

Honey o.ooi 

Bread, white 0.0009 

Rice 0.0009 

Potato, sweet .... 0.0005 

Water- and salt-rich foods : 

Dandelion greens . . 0.027 

Spinach 0.0032 

Dates 0.003 

Olives 0.0029 

Beans, lima 0.0025 

Almond 0.002 

Beans, string .... 0.0016 

Peas, green 0.0016 

Cabbage o.ooii 

Asparagus o.ooi 

Lettuce o.ooi 

Carrots 0.0008 

Com, green 0.0008 

Squash 0.0008 

Beets 0.0006 

Lemon 0.0006 

Radish 0.0006 

Celery 0.0005 

Cherries 0.0005 

Turnips 0.0005 

Tomato 0.0004 

Apples 0.0003 

Oranges 0.0003 

Peaches 0.0003 

Onions 

Fat- rich foods: 

Butter 

Cream 

Cocoa 





Weight of 


Fe in 100-Calorie 


lOO-Calorie 


portion, gm. 


portion, gm. 


. 0024 


29 


. 0023 


28 


0.002 


29 


0.002 


29 


0.0015 


28 


. 0009 


80-100 


. 0008-0 . 003 


35-50 


0.0019 


68 


. 0002Q 


14 


00013 


45-93 


0.0035 


.18 


. 00066 


273 


. 00034 


145 


. 0002 


196 


0.0014 


28 


. 0009 


25 


. 0006 


41 


. 0004 


28 


. 00036 


28 


0.0015 


120 


. 0003 


28 


. 0003 


31 


. 0003 


38 


. 0003 


29 


. 0004 


81 


. 0044 


164 


0.0133 


418 


O.OOI 


29 


0.0009 


33 


0.002 


82 


0.0003 


15 


0.0038 


241 


0.0016 


100 


• 0.0035 


317 


0.0043 


450 


0.005 


524 


0.0016 


221 


0.00075 


99 


o.oo'i7 


217 


0.0013 


217 


0.0013 


226 


0.002 


341 


0.0027 


540 




128 


0.0013 


254 


0.0017 


439 


0.0005 


159 


0.0006 


195 


. 0007 


242 


O.OOII 


205 


O.OOOI 


51 


0.0005 


20 



90 INORGANIC SALTS AND WATER 

that during gestation the fetus accumulates a store of iron. 
During the suckling period the quantity of iron is almost 
constant and milk is comparatively poor in iron. The con- 
clusion from these facts is, then, that the child derives from 
its mother, before birth, a store of iron sufficient for its needs 
throughout the period when it is nursing, and that the mother 
supplies, in the milk, approximately enough iron to replace 
the iron lost in the processes of metabohsm. After the child 
stops nursing it is important that the iron content of the diet 
be given careful consideration, for both the small daily losses 
made good by the milk and the iron needed for the processes 
of growth must be furnished. 

The degrees of availabiUty of iron, in the organic and inor- 
ganic forms has been, as in the case of phosphorus, a matter of 
great controversy. Experiments have shown that both forms 
of iron are absorbed from the small intestines. That inorganic 
iron may be used in the production of hemoglobin has not been 
proven, it does increase the production of hemoglobin, in which 
case it apparently acts as a stimulant to the cellular activities. 
Iron in simple organic combination, lactate, has been used 
successfully as the source of iron for growing rats. There is 
ample evidence that iron when found in organic combination 
is assimilated and used in the processes of growth and in the 
formation of hemoglobin. Although inorganic iron appears to 
be as effective as organic iron it has been recommended by some 
that at least a part of the iron ingested be in the *' organic'' form. 
Iron is ehminated chiefly in the feces. The table on page 8i 
contains the iron content of some of the more important foods. 

In using the table it is essential to remember that fat meat 
contains a smaller proportion of iron than does a lean piece, for 
fat contains practically no iron. The preparation of cereals 
for the market (milHng) results in the removal of a consider- 
able portion of the iron contained in the whole grain. The 
advantage of foods, such as vegetables and fruits, which are 
not particularly valuable to the body for protein or a source 
of energy, is shown when it becomes desirable to increase the 
inorganic salt content of the diet. 

IODINE REQUIREMENT OF MAN. 

Iodine is present in its greatest amount in the thyroid gland. 
The function of iodine in the thyroid is not known. The 
quantity of iodine in the gland is variable. Ingestion of iodine 
or the application of iodine to the skin is accompanied by an 
increased iodine content of the thyroid. It appears to be in 
combination with protein material. The name thyroglobulin 



WATER REQUIREMENT OF MAN 91 

has been given to an iodine-rich protein isolated from the thyroid 
gland. Regions in which the iodine content of the water 
is low have been shown to be, in many cases, those in which 
goitre is prevalent. If, as general observation seems to indi- 
cate, there is a relation between the lack of iodine and the 
prevalence of goitre, it is important to know the foods which 
contain iodine. 

Iodine is contained in the water of various districts; it also 
occurs in sea water and in foods grown near the sea. Recent 
analyses of foods have shown that iodine is not a constant 
constituent of foods; that when present it is usually found in 
exceedingly minute proportions, and that in general, at least, 
it must be regarded as an accidental constituent in the sense 
of standing in no vital relation to the growth of food prod- 
ucts. The presence of iodine in most vegetable food products 
clearly depends upon the fact of its presence in the soil and the 
lack of a selective capacity in the feeding of plants.^ Of the 
plants examined, Irish moss, from which blanc mange is pre- 
pared, and agar agar are the best sources of iodine. Garden 
vegetables, some kinds of legumes, or seeds, beans, and peas, 
are shown to be fair sources of iodine, although the presence 
or absence of iodine and the quantity contained are uncer- 
tain. Studies of foods from different sections of the country, 
particularly from localities in which goitre is prevalent, failed 
to show any uniformity in the presence or absence of iodine 
over districts which were comparatively free from goitre. 

WATER REQUIREMENT OF MAN. 

Water as an essential constituent of the diet receives very 
little attention in the usual consideration of the foods. That 
this is so is but natural, for it is one of the most readily obtain- 
able and generally used food-stuffs. The lack of water is, 
however, sooner and more keenly felt than the absence of 
protein, carbohydrate, or fat. An animal receiving neither 
food nor water will die sooner than one which is given only 
water; while an earlier death will result from dry food and no 
water. 

The relative importance of water from a quantitative point 
of view is indicated by the water content of the body tissues. 
The fat-free organs show a comparatively constant water 
content, being about 80 per cent. The presence of fat affects 
the percentage of water content of the tissues as a whole, but 
being inert so far as holding water is concerned, it does not 

1 Cameron: Jour. Biol. Chem., 1914, xviii, 335. Forbes and Beegle: Jour. 
Med. Research, 1916, xxxiv, 445. 



02 INORGANIC SALTS AND WATER 

appear to influence extensively the composition of the tissues 
which hold it. The secretions are particularly rich in water 
(86 to 99 per cent.), while the skeletal tissues, such as bone 
and connective tissue, have a much lower water content (lo 
to 50 per cent.). The tissues of young animals, of regenerating 
and probably of recuperating tissues are richer in water than 
those of an adult organism. 

The functions of water are numerous: it is a constituent of 
all protoplasm; as a solvent it aids in carrying to the cell the 
food material produced by digestion in the removal of the 
waste products; it maintains the osmotic equilibrium between 
the various organs and tissues; by reason of its high specific 
heat its evaporation assists in the maintenance of a constant 
body temperature; and it is the vehicle for the transportation 
of the blood elements throughout the body. 

The water present in the body is not necessarily to be consid- 
ered as free water in the sense that after its complete removal 
from the cellular structures the}^ will not cease their activities 
or that its return will initiate them anew. A certain amount 
of water is probably held in loose chemical combination or by 
physical attraction with the various molecular structures, such 
as the protein. It is known that much of the organic material 
in the body exists in swollen colloidal masses and that the 
removal of water from them affects their physical and perhaps 
their chemical properties. Our knowledge on this point is 
rather meagre. We do know, however, that the complete 
removal of water results in the disappearance of the phenom- 
enon known as life. Since the water content of various tis- 
sues IS relatively constant a decided diminution in the water 
content is fatal. Certain organisms, such as the frog, insects, 
etc., can lose a considerable proportion of their water under 
favorable conditions and still remain alive, although usually 
dormant; seeds exhibit similar phenomena. Water is never 
entirely absent under such conditions; there is a minimum 
which if passed, results in the disappearance of life. 

Water is ingested either as such or associated with food. 
Most water contains a considerable quantity of salt.^ The 
quantity of water ingested with the food may be considerable, 
for most foods roughly three-fourths its weight. A certain 
amount of water is liberated in the tissues as the result of 
oxidation. 

The quantity and manner in which water is excreted is 

^ The specific effects of certain mineral waters is due to tlieir salt content, 
it may be, however, that the increased water ingestion, under such circum- 
stances which usually accompanies the use of such waters, may also contribute 
to the beneficial effects of water cures. 



WATER REQUIREMENT OF MAN 93 

affected chiefly by the temperature and humidity of the sur- 
rounding air, the activity of the individual and the quantity 
and nature of the food and water ingested. Under normal 
conditions the equivalent of the water ingested in a day is 
excreted in a similar time chiefly through the lungs and skin, 
and in the urine and feces. A considerable proportion of 
the water ingested under average conditions of temperature and 
humidity appears in the urine within a comparatively short time 
after its ingestion. After large volumes of water have been 
taken as much as three-fourths of the amount appears in 
the urine within an hour after its ingestion. Higher tempera- 
tures outside the body, or excessive muscular activity increase 
the loss of water through the lungs and skin; while with low 
temperatures and relative quiet the amount of water which 
appears in the urine is increased. With an increase in the 
quantity of water ingested, other conditions being the same, 
a greater proportion of the ingested water appears in the 
urine. The body may suflTer a loss of water as the result 
of excessive perspiration, the action of diuretics or of cathar- 
tics. Under such circumstances the ingestion of water results 
in a restoration of the amount lost, for the tissues tend to 
maintain the concentration of water at a constant level. 

With the loss of water there is usually a loss of salt from the 
body either in the urine or through the skin. One investi- 
gator has studied this loss with regard to increased perspira- 
tion and the processes attending the restoration of water. 
He suggests that thirst resulting from excessive perspiration 
is quenched most readily by water containing salts, or taken 
with food, than with distilled water; for unless salt is present 
the water ingested will not be retained but will be rapidly 
excreted. In the process of recuperation following emacia- 
tion there is a ver}^ rapid restoration of the lost water. Thus 
the tissues of fasting animals which show an increased water 
content upon the ingestion of food and water, even though 
large quantities of water have been ingested throughout the 
fast, show a marked water retention. Because of the varied 
activities of man the quantity of water which is necessary for 
the normal functioning of the body is a difficult matter to 
determine. It has been placed at from 2 to 5 Hters (or 
quarts) per day. 

The effect of water on metabolism has been studied from 
many angles. Ingested water passes rapidly through the 
stomach and is readily absorbed in the intestines. In spite of 
this it has been shown that it aff'ects the rate and extent of 
digestion. Water taken into the stomach in large quantities 
increases the secretion of gastric juice; small amounts have no 



94 INORGANIC SALTS AND WATER 

effect. When water is taken with food the flow of gastric 
juice has been shown to be not only greater in amount but to 
contain more acid. The secretion of bile and pancreatic juice 
is also stimulated by water, probably because of the inter- 
relation between the acid reaction in the stomach and the 
flow of these secretions. The passage of food from the stom- 
ach has been held to be accelerated as the result of the inges- 
tion of water. This is not entirely correct, for it has been 
shown that there is a slight retardation of the passage of 
bread from the stomach when water is taken after bread. 
Experiments with fistulous animals and anatomical and A:-ray 
studies have shown, however, that water, when ingested alone, 
does not mix to any extent with the food mass in the stom- 
ach in its passage to the pylorus. A sort of trough is formed 
along the lesser curvature of the stomach through which the 
water flows from the esophagus to the pylorus. Practically 
neutral water has been observed to pass the pylorus when the 
stomach is full of food and the digestive processes are at their 
height. 

A large ingestion of water serves to increase the excretion 
of nitrogen in the urine. This eflPect is the result apparently 
of stimulated cellular activity and in part to a flushing out of 
the soluble nitrogenous end-products of metaboKsm. 

Mattill and Hawk have studied the influence of copious 
water drinking with meals and found a more complete utiliza- 
tion of food, protein, carbohydrates, and fat and decreased 
putrefaction and bacterial development in the feces. From 
the results of such work we may conclude that for the normal 
individual the ingestion of water with meals is not harmful. 

VITAMINES AND ACCESSORY FOOD-STUFFS. 

Investigations into the qualitative nature of food-stufi^s 
necessary to body activity, growth and of certain diseases, such 
as beri beri and scurvy, have led to the conclusion that there 
are substances, apparently not protein, carbohydrate, fat or 
salt per se which are vitally essential to normal nutrition. 
These substances have been designated "accessory substances" 
or "vitamines." They occur in both plants and animals but 
appear to be present in greater concentration in some foods 
than in others. While these substances are present in animal 
tissues, animals are apparently unable to synthetize them and 
are therefore dependent upon plants or other animals for their 
vitamines. Two types of accessory substances have been 
detected: one, designated "fat-soluble A," is soluble in fats 
and accompanies them when isolated from food-stufts. This 



VITAMINES AND ACCESSORY FOOD-STUFFS 95 

substance is widely distributed among natural food-stufFs and 
is relatively thermostable. It is associated with Hpins, such 
as those contained in butter fat, egg yolk, kidney fat, cod- 
liver oil and in relatively small quantities, but occurs in high 
concentration in the leaves of certain plants, particularly 
alfalfa and cabbage. The second type of accessory substance 
called "water-soluble B," is soluble in water and alcohol and is 
found in both the plant and animal world, e. g., in milk, eggs, 
meats, vegetables, and grains. It is thermolabile. The "water- 
soluble B" of McCollum is the vitamine of Funk, and is appar- 
ently the only accessory substance concerned in the cure of 
polyneuritis. 

A full recognition of the existence of such accessory sub- 
stances has come through two channels in particular, the study 
of deficiency diseases, such as beriberi and scurvy, and quali- 
tative studies of the diet, in which the rate of growth and 
incre ase inbody weight are taken as the critera of ist suffi- 
ciency or insufficiency. As an example of the first class of work 
we may take beriberi. In considering the diet of individuals sus- 
ceptible to beriberi it was noted that those living largely upon 
polished rice were more susceptible than those ingesting a diet 
of unpolished rice. It has been shown further that when 
chickens or pigeons are fed on polished rice they develop 
polyneuritis, a disease similar to beriberi, while those fed 
unpolished rice do not do so. They have therefore been used 
extensively in the study of substances capable of curing beri- 
beri. Analysis of rice polishings has shown them to be richer 
in phosphorus than other parts of the grain. Yet attempts 
to associate beriberi with phosphorus metabolism have had 
little success beyond showing that the accessory substances 
occur in those parts of grains rich in phosphorus. The 
injection of an alcoholic or water extract of rice polishings, 
of certain plants or of animal organs into birds affected with 
polyneuritis will bring about rapid recovery. Funk has made 
attempts to isolate the substance which is the active factor 
in such cures. He has obtained from rice polishings and 
autolyzed yeast a crystalline product possessing the property 
of curing polyneuritis even when given in as small quantities 
as a few milligrams. The exact nature of the material is 
unknown. Funk proposed the name vitamine for substances 
capable of curing "deficiency" diseases and suggests that it 
contains nitrogen of the amine type and that it is related to 
the pyrimidine nucleus. The substance prepared by Funk is 
soluble in water and alcohol, insoluble in ether, chloroform, 
benzene, and acetone; is destroyed by alkalis, but is more 
stable in the presence of acids; heat, that is by boiling for some 



90 INORGANIC SALTS AND WATER 

time, destroys it. It is readily absorbed by silicious earth, 
Lloyd's reagent, and extracts prepared by this method have 
been found to be quite effective. 

Williams^ has studied the effect of certain hydroxypyridine 
derivatives upon birds afflicted with polyneuritis gallinarum 
in an attempt to determine the nature of the vitamine of 
Funk. He found partial curative effects less satisfactory than 
the natural "vitamine" preparation with one of the isomeric 
forms of hydroxypyridine, while another isomer was entirely 
ineffective. From this and other considerations WilHams came 
to the conclusion that isomeric changes are at least partially 
responsible for the instability of "vitamines" in food-stufFs 
and that antineuritic properties may be related to certain 
types of isomerism. 

Other diseases associated with nutritional disturbances seem 
to result from a lack of certain factors other than protein, 
fat, carbohydrate, or salts in the diet. Scurvy results from 
the continued ingestion of a restricted diet of salted and pre- 
served food — including pasteurized milk in the case of infants — 
and is cured by the ingestion of fresh food, especially fruits 
and vegetables. Pellagra is held by some to be due to a lack 
of accessory substances in the diet as the result either of 
improper selection of food, their destruction during cooking 
or their removal in the process of milling. The effect of diet 
in pellagra may be only secondary in that a deficient diet may 
be a predisposing factor to infection due to a decreased 
resistance. 

The second source of our knowledge of accessory substances, 
studies in which the rate of growth has been taken as a 
criterion of the sufficiency or insufficiency of a given diet, has 
perhaps been more fruitful than the study of diseases in extend- 
ing our conception of their relation to nutrition in general. 
Such studies were initiated originally to learn the effect upon 
nutrition of variations in the amounts and kinds of amino- 
acids in the diet. It was in the selection of a suitable diet 
consisting of simple purified food substances which would form 
the basis for subsequent variations in the diet that the impor- 
tance of accessory substances for growth became evident. 

It has been shown (Hopkins and Wilcox; McCollum and 
Davis; Osborne and Mendel) that when rats are fed on a prac- 
tically fat-free diet, composed of protein (such as casein or 
edestin), starch, and a suitable salt mixture which was entirely 
sufficient with regard to its energy, protein, and salt content, 
they did not grow normally, nor did they maintain their weight. 

^ Jour. Biol. Cliem., 1916, xxv, 437. 



VITAMINES AND ACCESSORY FOOD-STUFFS 97 

The addition of lard to this diet yielded slightly better but 
still unsatisfactory results. When, however, milk was added 
to the mixture containing lard, growth would continue. In 
studying the constituents of milk which were responsible for 
this correction in the diet it was found that butter would 
accompHsh the same result. 

To determine which constituent of the butter carried the 
accessory substance, the butter fat was separated from the 
other constituents, protein, salts, and water, by centrifugalizing 
warm butter. When this purified butter oil, a substance 
practically free from nitrogen and phosphorus, was fed the 
results were just as satisfactory as those obtained from 
ordinary butter, indicating that the active agent was con- 
tained in butter fat. This substance (or substances) is resis- 
tant to heat and a certain amount of chemical action for 
butter which has been heated with live steam or subjected to 
the process of saponification does not lose its efficiency. The 
fats closely associated with metabolic activity are more effec- 
tive in maintaining growth than "storage" fats, lard, beef fat, 
etc., which are in general ineffective or less satisfactory. The 
substance contained in butter fat remains efficient for over a 
year; while "butter oil," in which it is more concentrated, 
begins to lose its efficiency in half a year and becomes entirely 
inefficient in a year, even when kept at o° C. and in the dark. 
Egg yolk fat, cod-liver oil, kidney fat, the ether extract of 
ripe cod testicle and forage plants also supply the sub- 
stances necessary for growth. The liquid portion of beef fat 
obtained by fractional crystaUization from alcohol will accom- 
pHsh similar results. Certain fats, such as lard, olive oil, cold 
pressed almond oil, the more soKd portions of beef fat obtained 
in the preparation of beef oil, as indicated above do not con- 
tain this substance or substances. The deficiency is not due 
to a lack of the Hpoids, lecithin and cholesterol, for phosphorus- 
containing substances are practically absent from butter oil, 
and lard contains a greater amount of cholesterol than butter. 
This active material bears certain quantitative relations to 
the diet, for there is a minimum value which must be present 
to produce results. 

McCoUum demonstrated the presence of a water-soluble 
accessory factor in experiments in which it was noted that 
while satisfactory growth was obtained with a diet in which 
fats from butter, egg yolk, kidney, and also from plants were 
added to a fat-free diet of casein, dextrin, lactose and a suit- 
able salt mixture, if the lactose of such a diet be replaced by 
dextrin, equivalent carbohydrate value, the diet was not 
effective in promoting growth. The addition of the water 
7 



98 INORGANIC SALTS AND WATER 

extract of egg yolk or the alcoholic extract of wheat germ to 
such a defective diet was sufficient to correct it. This led 
them to beheve that lactose carried a water-soluble factor and 
that there were two factors necessary for growth in addition 
to the customary food-stuffs. Investigations of various lac- 
tose preparations served to confirm the suspicion with regard 
to the presence of the water-soluble factor and it has since 
been demonstrated in a number of foods. Further studies 
have brought out with renewed emphasis the variety of fac- 
tors which must be considered and controlled in the regulation 
of the diet and the possibility and the danger of neglecting 
modifying factors in our zeal to correct the most apparent 
defects. It has been found that in the case of rats, a diet 
containing a proper supply of protein, energy, salts, and "fat- 
soluble A" and "water-soluble B'' may be apparently satis- 
factory for growth and reproduction, while a diet composed of 
naturally occurring food-stuffs may be inadequate because of 
the presence of a substance or substances which exert a toxic 
influence upon the body, but if to such a diet a substance 
containing a toxic substance be added, a failure to continue 
to grow may result. If, however, the protein portion of the 
diet be increased or a better, more complete protein be sub- 
stituted, the animal may continue to grow at a normal rate. 
The disturbances in metabolism accompanying a diet con- 
taining a large proportion of the wheat germ is apparently, 
in part, deficient for this reason. 

FASTING. 

The fasting state sometimes prevails in disease as a result 
of obstruction of the aHmentary tract or the inabiHty of the 
individual to retain ingested food. Conditions of under- 
nutrition from similar causes are much more common than 
complete fasting. Short fasts are often used in the treatment 
of various diseases. A knowledge of the changes in the body 
that result from fasting is of a purely scientific as well as prac- 
tical interest, for it aids in understanding and explaining the 
normal metabolism and certain pathological conditions. 

Life is accompanied by various cellular and systemic 
changes which we ordinarily designate as metabolism — pro- 
cesses of synthesis and of decomposition; oxidation with the 
hberation of carbon dioxide, water, and energy; the formation 
and disintegration of proteins, and the coordination of these 
activities in all parts of the body. Even though food no 
longer be supplied these processes continue. Since the losses 
sustained in metabolism are then no longer replenished from 



FASTING 99 

ingested material, the more active and essential organs make 
use of similar substances contained in the body. Thus we 
find that the heart, brain, lungs, kidneys, testicles, and liver 
lose a much smaller proportion of their weight during fasting 
than do the muscles and adipose tissue. From this we con- 
clude that the former organs which are, in a sense, more essen- 
tial for life obtain the necessary food material from the blood 
which in turn is replenished largely from the muscle and 
adipose tissue. This process of drawing upon the tissues for 
continued activity is not an unusual one. There are undoubt- 
edly times between the ingestion of food, particularly late dur- 
ing the long interval between the evening meal and breakfast, 
when but little food is received from the alimentary tract and 
the body lives at the expense of its own stores. 

Not only does the body draw upon its own tissues for the 
material necessary for its activity but it appears to be able to 
utiHze these much more economically than it does ingested 
food. In the light of our present knowledge of protein 
metabolism in which, as McCollum has expressed it, the pro- 
cesses of repair do not involve the destruction and resynthesis 
of entire protein molecules, it seems quite probable that one 
tissue is able to utiHze in part the amino-acids which have 
been removed from material in another tissue and that the 
more or less complete disintegration of protein in one part of 
the body serves to supply material for the repair of the losses 
from a number of different tissues in other portions of the body. 

The activity of the kidneys, liver, and digestive tract are 
reduced to a minimum in fasting, for they are no longer 
required to take care of an excess of food-stuffs. The kid- 
neys are concerned only with the elimination of the products 
of endogenous metabolism which, as we know, is« small in 
comparison with the exogenous metabolism of the average 
individual. The elimination of abnormal urinary constituents, 
as aceto-acetic acids and /^-hydroxy butyric acid or bile con- 
stituents is sometimes imposed upon the fasting kidneys. 

The period of time during which an organism may fast 
depends upon a number of factors. The previous nutritive 
condition has its effect in that the quantity of fat and protein 
which are available determines in part the body reserves. The 
size of the individual affects the rate of metabolism; small 
persons have in general a greater metabolism for the body 
weight than a large person. Age is accompanied by a varied 
rate of metabolism; children metabolize at a greater rate 
than adults and therefore utilize their body stores more rap- 
idly than an adult. The external conditions surrounding the 
body, such as temperature and humidity, may either increase or 



100 INORGANIC SALTS AND WATER 

decrease the body activities. The ingestion of water tends to 
lengthen the period an organism may fast as compared with a 
fast without water. Finally, fasting experience in a given 
individual is a modifying factor; as the result of repeated 
fasts the body appears to acquire such a resistance that it is 
better able to withstand the effect of each subsequent fast. 
This appears to be particularly true when the organism is 
permitted to recover from the previous fast before being 
subjected to another. 

Men have fasted for as long as fifty days without apparent 
harm. There are authentic records of a number of thirty-day 
fasts. Benedict^ has recently reported the result of a most care- 
ful study of a thirty-one-day fast by a man. Animals have been 
known to fast for much longer periods. The longest fast of a 
warm-blooded animal is that observed in a dog which con- 
tinued for 117 days, after which the animal was fed and restored 
to its original condition and fasted again for the second longest 
fast, 104 days. Cold-blooded animals, such as the frog, salaman- 
der, etc., have been known to fast for much longer periods of 
time. It is evident, therefore, that the body can obtain from 
itself sufficient material on which to exist for a considerable 
length of time. Death, as the result of fasting in the case of 
normal individuals, is probably due to the failure of some organ 
or tissue and not to the complete utilization of the body stores. 
Certain investigations seem to show that a definite minimum 
quantity of nitrogen-containing material is necessary in order 
that life may exist. 

During a fast the general rate of metabolism is lowered. 
Studies of the respiratory changes show that the total quan- 
tity of carbon dioxide excreted per day is lowered, and the res- 
piratory quotient falls to a value which indicates the oxida- 
tion, chiefly, of fat and protein. Protein metabolism is also 
decreased; the daily nitrogen excretion after the first few days 
becomes low and fairly constant. It may fall as low as 4 to 6 
grams of nitrogen per day. The excretion of salts is also 
diminished. All phases of normal body metabolism are greatly 
reduced in fasting. 

^ Benedict has reported a very complete experiment on a man during a thirty- 
one-day fast, Carnegie Institution of Washington, 1914, Pub. No. 203. The 
data from this fast are pubHshed in chart form in Mathews's Physiological 
Chemistry, New York, 19 15. 



CHAPTER V. 
NORMAL FEEDING AND FOOD ECONOMICS. 

The application of the principles of human nutrition to the 
feeding of the normal individual or to the family group is at 
once involved and difficult. Though the scientist may deter- 
mine and the physician prescribe an ideal dietary, its adop- 
tion by the individual may be quite impractical, due to cost, 
inconvenience, or lack of market facilities. But since foods are 
interchangeable within wide ranges, a summary of the prin- 
ciples of nutrition which underUe the selection of food, together 
with typical menus and a discussion of the cost of food may 
aid in the interpretation and application of these principles. 

Our previous discussion of the various food-stuffs and their 
digestibility has shown that the source of food is of no par- 
ticular importance so long as it possesses all of the necessary 
material and is wholesome, that is, does not contain or yield 
products which are detrimental to the health of the normal 
individual. For example, disregarding for the moment, the 
psychological factor, the stomach and intestines can digest a 
cheap cut of meat or fish as thoroughly as an expensive steak; 
American cheese as well as Roquefort cheese; cotton-seed oil 
as well as olive oil. The psychical factor cannot, however, be 
completely ignored for two reasons: 

1. Studies of the secretion of the digestive juices and of the 
rate with which food passes from the stomach indicate that 
appetite, which in its psychological sense is to a large extent 
the reflex of palatability, serves to stimulate an early flow of 
gastric juice and thus facilitate digestion. Once a food is 
digested and absorbed its value to the body is mainly a 
matter of its intrinsic composition. 

2. A diet which contained all of the necessary food fac- 
tors might still prove to be unsatisfactory because of psychi- 
cal objections on the part of those who are to eat it. Such 
factors as habit, taste, and custom must be taken into con- 
sideration. The likes and dislikes for food are to a large 
degree governed by the kind and variety of food, method of 
preparation, etc., which have been observed in the household 
or community in which individuals are reared — a change of 
the usual dietary regimen is accepted with hesitation, which 
can only be overcome by palatability or force of will. If, 
in the latter case, the diet prove to be unsatisfactory, its 



102 NORMAL FEEDING AND FOOD ECONOMICS 

continuance is accomplished with greater difficulty or not at 
all. On the other hand, food well prepared is usually accept- 
able. It is the factor of palatability, based largely upon the 
proper selection and preparation, which determines the success 
or failure of diets selected because they are economical. Pala- 
tability is, as we have said before, entirely a relative factor, 
tempered by custom. The diet of the Eskimo, rich in fat and 
very high in protein, is apparently satisfactory to him. The 
peasant's diet of porridge and black bread is acceptable, while 
added white bread or meat constitute luxuries. The absence 
of choice meats, rich sauces or sweets from the diet of the 
well-to-do American is regarded as a hardship. A variation of 
diet outside the range of the dietary habits is a matter of 
acquired taste or necessity. When it is necessary or desirable 
to cause a marked change in a diet, careful preparation and 
serving will do much to accomplish that purpose. 

A diet which will supply the needs of the body must 
contain: 

{a) Energy-yielding food sufficient in quantity to supply 
the basal energy requirement and to meet the increased need 
resulting from activity. The energy may be derived from the 
oxidation of protein, carbohydrate, or fat, although the require- 
ment beyond that obtained from the protein necessary in other 
relations, and a minimum amount of fat, is satisfied chiefly 
by carbohydrates. 

ih) Protein, containing the necessary amino-acids, or in 
variety which will yield them in sufficient amount. 

(f) Carbohydrate. 

{d) Lipins (fat), natural and unmodified. 

{e) Mineral matter — salts in quantities and kind sufficient 
to maintain the skeletal structure, equiUbnum between the 
fluid portions of the body, and to supply the specialized needs 
of protoplasm in general and of certain organs in particular. 

(/) Substance of unknown chemical nature classed as 
accessory food-stuflPs, termed vitamines, found particularly in 
vegetables, coverings of grains and in fatty material. Pre- 
served or highly milled foods are less likely to contain these 
substances than raw or freshly prepared food. 

{g) Bulk or indigestible material to stimulate peristalsis. 

Ch) Water. 

The absolute quantities of the various food-stufPs needed 
vary with the size, age and activity of the individual concerned, 
and with the external conditions to which he is subjected. 

The quantitative food requirements of man are as follows: 

Energy. — Forty Calories per square meter of body surface 
per hour plus the energy required for general activity; increased 
muscular work and external conditions. The daily require- 



SELECTION OF DIET 103 

ment for the average individual at various ages and activities 
may be found on pages 64 and 65. 

Protein. — Equivalent to 10 to 15 per cent, of the total 
calories required per day. For the adult this amounts to from 
60 to 120 grams per day. 

Carbohydrate and Fat. — ^The total quantity and the relative 
proportions of these food-stuffs vary with the energy require- 
ments. It has been found that fat and carbohydrate may be 
used in the diet in the proportion of 7 to 2 without apparent 
marked disturbance in metaboHsm. The average diet, how- 
ever, contains a preponderance of carbohydrate. The average 
fat intake is from 25 to 75 grams per day. 

Mineral Matter. — With the exception of phosphorus, cal- 
cium and iron, Uttle is known in regard to quantitative 
requirements. The quantities of inorganic constituents which 
are required daily by the average individual have been esti- 
mated as follows: 

Grams. 

Phosphoric acid (P2O5) 2 . 75 

Calcium oxide (CaO) ; . . o . 70 

Iron (Fe) 0.015 

Accessory Foods and Bulk. — ^The average mixed diet contains 
sufficient quantities of these substances. For further discussion 
see pp. 94 and 204. 

The following typical menus prepared by Miss Rose as 
suggestions in planning the diet of a family of moderate means, 
including children above two years of age, may be regarded as 
illustrations of properly selected diets. Certain foods, as pan- 
cakes and sausages, are included to increase the variety for 
adults who are accustomed to a more varied diet than children. 

Menu I. 
Breakfast: 
Wheaten grits with cream or whole For all members of the family. 

milk. 
Oranges. For all members of the family except 

very little children, to whom orange 
juice may be given between meals. 
Bread and butter. For all members of the family. 

Sausages. For adults. 

Pancakes. For adults. 

Coffee. For adults. 

Dinner: 
Soup. For adults and older children. 

Roast mutton. For all members of the family except 

children under seven years of age. 
Baked potatoes. For all members of the family. 

Spinach. For all members of the family. 

Bread and butter. For all members of the family. 

Milk to drink. Especially for children. 

Apple pie. For adults. 

Apple sauce. For children. 

(An egg for children under seven years of age may be included in the above meal 
plan.) 



104 



NORMAL FEEDING AND FOOD ECONOMICS 



Supper: 
Milk toast. 
Scrambled eggs. 
Bread and butter. 
Peach sauce 
Cookies. 



Menu I. — (Continued.) 



For all members of the family. 
For adults. 

For all members of the family. 
For all members of the family except 
veiy small children. 



Menu II. 



Breakfast: 
Rolled oats with cream or whole milk. 
Stewed prunes. 
Bread and butter. 
Milk to drink. 
Eggs: 

Poached. 

Fried. 
Coffee. 

Dinner: 
Soup. 
Pot roast. 
Boiled potatoes. 
Creamed onions. 
Bread and butter. 
Milk to drink. 
Custard pie. 
Baked custard. 

Supper: 
Scalloped rice with cheese. 
Plain boiled rice with cream or whole 

milk. 
Bread and butter. 
Milk to drink. 
Fruit sauce or baked apples 
Molasses cookies. 

Menu 
Breakfast: 
Cornmeal mush with cream or whole 

milk. 
Stewed fruit. 



Bread and butter. 
Milk to drink. 
Bacon. 
Waffles. 
Coffee. 



Dinner: 
Baked Hamburger steak. 

Creamed potatoes. 
Mashed potatoes. 
Buttered carrots. 
Bread and butter. 
Milk to drink. 
Steamed suet pudding. 
Baked apples. 

Supper: 
Cream of bean soup. 
Bread and butter. 
Prune sauce. 
Sponge cake. 



For all members of the family. 
For all members of the family. 
For all members of the family. 
For all members of the family. 

For children. . 
For adults. 
For adults. 

For adults and older children. 
For adults and older children. 
For all members of the family. 
For all members of the family. 
For all members of the family. 
Especially for children. 
For adults. 
For children. 

For adults and older children. 

For younger children. 

For all members of the family. 

Especially for children. 

For all members of the family. 
III. 



For all members of the familv. 

For all members of the family except 

very little children; to be given to 

children between meals. 
For all members of the family. 
Especially for children. 
Especially for adults. 
For adults. 
For adults. 

For all members of the family except 
children under seven years of age. 
For all members of the family. 
For small children. 
For all members of the family. 
For all members of the family. 
Especially for children. 
For adults. 
For children. 



For all members of the family. 
For all members of the family. 
For all members of the family. 
For all members of the family. 



SELECTION OF DIET 



105 



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106 NORMAL FEEDING AND FOOD ECONOMICS 

The table on page 105 suggests the fuel value or calories for 
the meals of a day apportioned among the various types of 
foods suitable for persons of different ages, under normal 
conditions. 

In this table a distinction is made between the starch-rich 
vegetables which supply considerable quantities of energy in 
the form of carbohydrates and the green vegetables which 
are particularly valuable for the bulk which they give to the 
contents in the alimentary tract, because of the indigestible 
cellulose contained, and for the salts and accessory substances 
in which they are particularly rich. The dishes classed as 
meat may often be combined with another class of food such 
as starch-rich foods or milk, as for example meat-pie, creamed 
beef, or oyster stew. 

It must again be emphasized that the physician who pre- 
scribes as well as the housekeeper who plans meals for a fam- 
ily must be sufficiently familiar with the composition of most 
of the common foods to be able to class them as valuable 
sources of protein, fat, carbohydrate, or salts. If they do not 
possess this knowledge one type of food may exceed its most 
satisfactory proportion in the diet. It is necessary, too, that 
correct dietary habits be estabHshed by children. Prefer- 
ence for a particular food must not lead to the habit of ** mak- 
ing a meal" of it. Likes and dislikes for food are largely a 
matter of habit, and the importance of an early establishment 
of good food habits cannot be overestimated. While it is not 
necessary that each meal or the combined meals of one day 
be complete in meeting the requirements of an individual, 
such a balance should be approximated and satisfied at least 
within the course of a few days. The following menus, and 
the table giving the relative proportion of protein, fat and 
carbohydrate in them, will serve to illustrate the possibility 
that even in an apparently well selected diet, some one food- 
stuff may predominate. 

Examples of one-sided diets, predominantly protein, fat, or 
carbohydrate and an analysis of their composition have been 
given by Langworthy.^ 



Menus with Protein Predominating. 

Breakfast: Cereal cooked in milk, chicken hash with egg, 
popovers, butter, and milk as a beverage. 

1 Scientific Monthly, 1916, ii, 294. 



SELECTION OF DIET 107 

Dinner: Dried-bean puree, halibut steak, potatoes scal- 
loped in milk, tomatoes stuffed with chopped beef, bread and 
butter, and frozen custard with nut cookies. 

Lunch or Supper: Baked beans, nut bread and butter, old- 
fashioned rice pudding, and a glass of milk. 



Menus with a Large Proportion of Fat 

Breakfast: Oatmeal with cream, sausage, and corn bread 
and butter. 

Dinner: Cream of tomato soup, mutton chop with creamed 
potatoes, greens cooked with bacon or pork, bread, and suet 
pudding with hard sauce. 

Lunch or Supper: Creamed salmon, lettuce with oil dressing, 
tea biscuits and butter, pumpkin pie and a cup of chocolate. 



Menus with Carbohydrate Predominating. 

Breakfast: An orange followed by corn cakes with maple 
syrup, and bread or toast and butter. 

Dinner: Meat pie and baked potato, green peas, bread and 
butter, and cottage pudding with chocolate sauce. 

Lunch or Supper: Rice croquettes with jelly, rye bread and 
butter, baked apples, and sugar cookies. 

The Composition of the Nutrients and the Energy Supplied by 

THE ABOVE MeNUS UsED FOR ILLUSTRATION. 





Weight of 






Carbo- 






edible food 


Protein, 


Fat, 


hydrates, 


Fuel value, 




served, gm 


gm. 


gm. 


gm. 


Calories. 


Protein meals: 












Breakfast 


. 471 


36 


50 


54 


810 


Dinner 


772 


58 


64 


120 


1288 


Lunch or supper 


639 


33 


38 


105 


894 


Total . . 


. 1882 


127 


152 ' 


279 


2992 


Fatty meals: 












Breakfast 


. 353 


24 


69 


58 


949 


Dinner 


. 617 


33 


88 


108 


1356 


Lunch or supper 


. 621 


29 


83 


98 


1259 


Total . . 


• 1591 


86 


240 


264 


3564 


Carbohydrate meals: 












Breakfast . . 


509 


15 


32 


168 


1020 


Dinner 


529 


40 


33 


133 


989 


Lunch or supper 


• 376 


H 


27 


127 


807 



Total . . . 1414 69 92 428 2816 



108 NORMAL FEEDING AND FOOD ECONOMICS 

Cost of Food. — No discussion of the question of normal nutri- 
tion is complete without a consideration of the cost of food. 
To those persons into whose hands falls the planning of a dietary 
for the normal family, the problem is not entirely one of 
furnishing a diet in which correct relative amounts of pro- 
tein, fat, carbohydrate, mineral constituents as well as 
accessory substances are provided. Their problem is, in addi- 
tion, to select such a diet which can be suppHed at a cost not 
exceeding a fair proportion of the income of the family. 

The following table shows the proportion of the income to 
be spent for food, suggested by the Russell Sage Foundation, 
as suitable for the normal family, consisting of father, mother, 
and three children. 

Proportion of Income to be Spent for Food. 

Income 
per year. 

$500 
800 
1000 
1 100 
1200 
1500 
2000 

Fortunately there is not a direct relation between the cost of 
food and its nutritive value. An inexpensive diet, so far as 
the needs of the body are concerned, may be as satisfactory 
as an expensive diet. Too often, however, lack of knowledge 
and training in the selection and preparation adds unduly to 
the cost of food, especially among the poorer classes who can 
least afford unwise expenditures. 

The physician is particularly interested in prescribing a 
diet which contains the special nutrients needed by his patient 
at a cost within the means of the family. Too often diet 
lists are not flexible, although good results might be obtained 
by the use of other and less expensive equivalents. The work 
of Hess in studying the effect of extract of orange peel and 
potato water as a preventative of scurvy in infants has shown 
possibilities in this direction. 

It would seem, then, incumbent upon the purchaser of the 
family food supply to familiarize herself with the composi- 
tion of the common foods and at least roughly with the cost 
in relation to their total food values. The following tables 
show foods typically high and low in cost in proportion to 
their food values.^ 

1 Bcvicr: Planning of Meals, Univ. of 111. Bull., 1914, xi, No. 30 



Percentage for 


Total for food 


food per year. 


per year. 


550 


$275 


45-6 


365 


450 


450 


44.6 


490 


450 


540 


36.8 


552 


30.0 


600 



mount per day 






for family of 


Amount per day 


five. 


per person. 


I0.75 


$0 


15 


1. 00 




20 


1.20 




24 


1-34 




27 


1.48 




29 + 


1.50 




30 


1.64 




33 



COST OF FOOD 



109 



Foods Low in Cost in Proportion to Their Total Food Value.^ 2 













Grams of 




Cost per 








protein in 




pound 


Calories Ounces in 


Cost of 100 


100-Calorie 


Kind of food. 


(Jan.. 1913). 


per pound. 100 Calories. 


Calories. 


portion. 


Cornmeal 


. $0,025 


1655 


96 


$0.0015 


2-59 


Wheat flour . . 


. .03 


1655 


96 


.0018 


3-87 


Oatmeal .... 


• -45 


i860 


86 


.0024 


4.20 


Sugar, granulated . 


.06 


i860 


86 


.0032 


0.00 


Beef heart . . . 


.05 


1320 I 


21 


.0037 


6.40 


Beans, navy dried . 


.062 


1605 


99 


.0038 


6.82 


Cross ribs of beef . 


.08 


1765 


906 


.0040 


5.10 


Lard, best leaf . 


.18 


4220 


37 


.0040 


0.00 


Potatoes at $1 bushel 


.016 


385 4 


15 


.0041 


2.64 


Peanuts, shelled 


.12 


2560 


62 


.0046 


4.69 


White bread 


.07 


1225 I 


30 


.0057 


3.60 


Brisket of beef . 


.07 


1165 I 


37 


.0060 


4.90 


Rice 


.10 


1630 


98 


.0061 


2.28 


Oleomargarine . 


.22 


3525 


45 


.0062 


0.00 


Flank of mutton 


•125 


1900 


85 


.0065 


3-75 


Bacon .... 


.20 


3030 


52 


.0066 


1.68 


Dates .... 


.10 


1450 I 


10 


.0068 


0.61 


Corned beef 


.14 


1990 


80 


.0070 


5.22 


Skim milk at |o.io gal. 


.0125 


170 9 


40 


.0073 


9.26 


Whole milk at $0.10 qt 


.046 


314 5 


09 


.0101 


4.76 


Salt mackerel 


.10 


1155 I 


38 


.0086 


565 


Butter .... 


•36 


3605 


44 


.0099 


4-54 


Cheese, cheddar 


.22 


2145 


74 


.0120 


6.50 


Walnut meats . 


•45 


3300 • 


48 


.0139 


2.61 


Round steak 


•15 


895 I 


70 


.0167 


12.62 



Foods High in Cost in Proportion to Their Total Food Value.^ ^ 

















Grams of 


Cost per 








protein in 


pound 


Calories 


Ounces in 


Cost of 100 


100-Calorie 


Kind of food. (Jan., 1913). 


per pound. 


100 Calories. 


Calories. 


portion. 


Mushrooms . . . . $0.65 


210 


7.6 


$0,309 


$7^54 


Lettuce . . . 






15 


75 


21.3 


.200 


5 44 


Lobster, fresh . 






25 


140 


II. 4 


.178 


19.07 


Black bass . . 






30 


205 


7.8 


.146 


20.56 


Chicken, broiler 






30 


295 


5-4 


.101 


19.6 


Sweetbreads 






80 


825 


1-93 


•095 


9-05 


Oysters . 






20 


230 


6.9 


.087 


12.27 


Cauliflower . 






12 


140 


II. 4 


•085 


8.16 


Rhubarb 




' 


05 


65 


24.6 


.077 


2.79 


Celery . . . 






05 


70 


22.8 


.070 


4.08 


White fish . . 






20 


325 


4-9 


.061 


14.72 


Oranges . 






10 


170 


9-4 


.058 


1.6 


Tenderloin of beef 






60 


1330 


1.2 


•045 


551 


Porterhouse steak 






30 


IIIO 


1.44 


.027 


7.8 


Sirloin steak 






25 


985 


1.62 


.025 


7.58 


Roquefort cheese 






45 


1700 


•94 


.024 


6.02 


Leg lamb, medium fat 




18 


870 


1.80 


.020 


8. II 


Rib roast, medium \ 


at 




20 


1155 


138 


.017 


552 



^ Based on Bulletin 28, "Composition of American Food Materials." Office of 
Experiment Stations, U. S. Dept. of Agriculture. 

2 The prices given do not apply to the present time (191 7), when the cost of 
food may be considered as abnormal. It has seemed best, therefore, to give 
prices which obtained previous to 191 4. These prices are to be considered as 
representing the comparative monetary value of food. 



no 



NORMAL FEEDING AND FOOD ECONOMICS 



It is readily seen from such tables that but few foods 
are obtainable at a cost of less than one-third of a cent per 
lOO Calories and that few of the foods in the first table are 
perishable or difficult of transportation. Fresh fruits and 
vegetables, fresh meat, milk and eggs all cost one cent or 
more per lOO Calories. 

Lusk and Murlin have suggested that the labels on food 
containers should indicate the energy value of the contents and 
the percentage of protein contained. The nature of the proteins 
would be indicated by letters — complete proteins, such as 
animal proteins would be designated as Proteins, of "Grade 
A," while incomplete proteins, such as gelatin, would be 
"Grade D." Mixtures of complete proteins "A" and incom- 
plete proteins "D" are in what would be marked "Grade B," 
while foods contammg a large proportion of incomplete pro- 
tein, as corn, would belong to "Grade C." The label might 
read : "This can contains X calories of which Y per cent, are in 
protein of "Grade C." 

Mention should be made of the work of Gephart and Lusk 
upon the cost of portions of food sold in the Childs restau- 
rants in New York City. A tabulation of their results shows 
the purchasing power of five cents in these restaurants. 

These data indicate strikingly that a wise choice means a 
sufficient meal at a low cost, while poor judgement may result 
in a low food value at a much higher cost. 

Purchasing Power of Five Cents in Childs' Restaurants. 



Orders, classed as: 




Highest of class in 
fuel value. 


1 

ml 


Lowest of class in 
fuel value. 


i 




< 




6 







Pastry . . . 


233 


Napoleon 


45 


Strawberry short- 
cake 


92 


Beans 


204 


Boston baked 


308 


Boston baked beans 
"on the side" . 


134 


Sandwiches . 


180 


Roast-beef sand- 




Sliced chicken 








wich with roll 


358 


sandwich . 


78 


Dairy dishes 


174 


Milk crackers 


317 


Cream of wheat . 


63 


Meats . . . 


174 


Lamb croquettes 
and mashed 
potatoes . 


291 


Deviled crab . 


83 


Oysters . 


149 


Oyster pie 


220 


Raw oysters . 


19 


Eggs .... 


141 


Plain omelet 


231 


Poached eggs on 
toast 


66 


Salads . . . 


136 


Potato salad 


217 


Crab-meat salad . 


100 


Soups 


116 


Beef stew 


251 


Tomato soup with 
rice .... 


37 


Fruits . . 


89 


Baked apple with 
cream . 


196 


Cantaloupe 


12 



COST OF FOOD 



111 



In this connection a summary of a series of menus suggested 
by Miss Rose, shows modifications to comply with cost within 
certain limitations. A detailed study of quantities used, with the 
proportion of protein calories to total calories, is given by her 
to show how the total fuel value may be maintained within 
safe margins, though the cost of the first menu, ij to 2 cents 
per lOO Calories, is reduced to | to f cent per lOO Calories in the 
fourth menu. 



Typical Menus of Varying Cost of a Family of Eight.^ 



Requirements of family (man, woman, baby one year, boy three years, 
years, boy twelve years, grandmother ninety years). Protein Calories, 1424- 
14,252. 



Menu I. 
l|-2 c. per 100 Cal. 



Oranges. 



Wheatena 

milk. 
Puflfy omelet 

bacon. 



with top 
with 



Toast, coffee, milk. 



Creamed chicken on 

toast. 
Baked bananas. 
Boston brown bread. 
Rice pudding. 
Tea, milk. 



Consomme. 

Baked halibut, egg 

sauce. 
Potatoes on half shell. 
String beans, buttered. 
Bread and butter. 

Tomato salad, French 

dressing. 
Apple snow with boiled 

custard. 
Lady fingers. 



Menu II. 
U-U c. per 100 Cal. 



Menu III. 
i-1 c. per 100 Cal. 



Breakfast. 



Oranges (small). 

Wheatena with 
milk. 



Toast, coffee, milk. 



Bananas (prune pulp 
for two youngest) . 
top Wheatena with top 
milk. 



Toast, coffee, milk, cer- 
eal coffee. 



Creamed dried beef on 

toast. 
Baked bananas. 
Boston brown bread. 
Rice pudding. 
Tea, milk. 



Mid-day Meal. 

Macaroni and cheese. 



Stewed apricots. 
Boston brown bread. 
Oatmeal cookies. 
Tea, milk. 



Evening Meal. 



Baked halibut, white 

sauce. 
Potatoes on half shell. 
String beans, buttered. 
Bread and butter. 

Cold slaw. 

Chocolate blanc mange 

cream and sugar. 
Plain cookies. 



Creamed salt cod. 

Baked potatoes. 
Boiled onions. 
Bread and butter. 



Rice pudding, cream 
and sugar. 



Protein Calories, 2202. Protein Calories, 2106. Protein Calories, 1791. 
Total Calories, 14,410. Total Calories, 14,414. Total Calories, 14,330/ 



two girls six and nine 
2061. Total Calories, 

Menu IV. 
f-f c. per 100 Cal. 



Stewed dried apples. 

Cornmeal mush with 
milk and sugar. 

Bread, pork fat; sau- 
sage for father and 
mother. 

Cereal coffee for older 
children and adults. 

Milk. 



Baked samp, with 

cheese. 
Stewed raisins. 
Oleomargarine. 
Brown bread. 
Oatmeal wafers. 
Tea for adults, cocoa 

for children. 



Beef stew with vege- 
tables. 



Bread and oleomargar- 
ine. 



Date pudding 
liquid sauce. 



with 



Protein Calories, 1526. 
Total Calories, 14,299. 



The factors which influence the cost of various foods are, 
as we have noted before, in many cases independent of their 
food values, but depend upon quite external conditions, such 
as source, perishability, supply and demand, proportion of 
waste, etc. This is particularly true of our most expensive 
food-stuflFs. An understanding of the relative cost of food 
necessitates, therefore, a knowledge of the factors which 
underUe the relation between food value and cost. 



^ Rose: Feeding the Family, New York, 191 6. 



112 NORMAL FEEDING AND FOOD ECONOMICS 

Our food is derived from two sources, animal and vegetable. 
Animal foods are particularly valuable as a source of protein 
and fat; they contain little carbohydrate. Vegetable foods 
are our chief source of carbohydrate, and they are to a less 
extent a source of protein. Both animal and vegetable food 
supply inorganic salts and accessory substances; green vege- 
tables are valuable largely because of these materials. 

Food derived from animals fed with cultivated fodder is 
much more expensive than the vegetable foods used in its 
production. This is true because animal food is developed 
largely at the expense of vegetable food; a process the efficiency 
of which is comparatively low. Furthermore, animals must 
often be kept for a period of years for their proper develop- 
ment, during which time they must be carefully tended; 
and they are also subject to disease with the possibiHty 
of loss by death. Flesh foods obtained from wild animals, 
such as fish and game, might be relatively cheaper because 
the only factors of cost involved are those of catching or 
killing the animals, preserving and sending them to the 
market. Although game may be procured cheaply, it is expen- 
sive to the average individual because of its scarcity. Similarly, 
fish is expensive in certain parts of the country because of 
the cost of transportation and storage. 

The perishability of fresh animal food also tends to make it 
expensive. With the exception of the isolated fat products, 
meat decomposes rapidly at ordinary temperatures. It must 
be preserved therefore by processes which are comparatively 
expensive, such as refrigeration. Furthermore, care must be 
exercised in handUng it to prevent contamination. In addi- 
tion there is a certain loss by deterioration when such food 
passes through the hands of the retailer, and this loss must be 
made good in the price charged for the remainder. 

Various methods of preservation of animal food in com- 
mon use operate to lower its cost to the consumer. Cold 
storage or refrigeration is a comparatively expensive process of 
preservation and tends to increase the cost of flesh foods; 
in spite of this it is a means of actually reducing the cost 
of such foods because it permits the slaughter of animals in 
large quantities and their transportation to the consumer with 
a relatively low loss by deterioration. Refrigeration permits 
the storage of other perishable animal food, such as eggs, in 
seasons in which they are plentiful. The net result of such 
preservation is a gain to the consumer, for while it tends to 
increase the cost when the foods are in season, it brings the 
cost of the same food out of season below what it would be 
were there no refrigeration. 



COST OF FOOD 113 

Other methods of preservation, such as drying (beef and 
fish), smoking, pickling, and canning, which do not require 
extensive refrigeration and which are performed where the 
supply is plentiful, also tend to lower the cost of animal foods. 
Processes which involve special manipulation of the food, such 
as the preparation of cheese and the extraction of fat, are 
also means of lowering the cost of animal foods. 

Plant foods are cheaper sources of food material than animal 
foods. They are used directly and the only loss to the body 
is that which results from a failure to absorb or to utilize them 
completely. Their cultivation is comparatively simple, and 
they mature in one season. Artificial preservation is not so 
essential and, when practised, is comparatively cheaper than 
the preservation of more perishable foods in their natural 
state. Plant foods, such as carrots, potatoes and apples 
when ripe can be stored for some months; with little 
deterioration; with a slightly increased expense for cold 
storage they may be kept for even longer periods. Foods 
which would decay at ordinary temperatures, such as oranges, 
can be preserved in cold storage. Many plant foods are pre- 
served in the dry state. Some become relatively dry before 
they are gathered, such as the legumes — beans and peas — and 
the grains — corn, oats, and wheat; while other foods used 
extensively in the fresh state — prunes, apples, apricots — are 
dried under special, artificial conditions. Milling of cereals 
and grains helps to extend the period of preservation without 
deterioration; this is particularly true of fat-rich grains, such 
as corn. Some plant foods, such as corn, peas, and tomatoes 
may also be preserved in the fresh, water-rich state by canning. 
This is done at times when they are plentiful and in districts 
in which they are produced, thus furnishing a supply of these 
foods at reasonable prices during seasons in which they would 
otherwise be unobtainable. 

Many foods which appear cheap, i. e.y are sold at a low cost 
per pound, are in reality expensive on account of the large 
amount of waste in skin, bone, seeds, etc.; for example, 
a chicken weighing 4.65 lbs., costing 16 cents per lb. aUve, 
weighed 4.09 lbs. dressed, and yielded but i.ii lbs. cooked 
meat, which brought the cost up to 74 cents per pound. 
Small prunes prove more expensive than larger ones costing 
5 to 8 cents per lb. more, owing to the greater waste in skin 
and seeds of the smaller prunes. 

The cost of food is also influenced by supply and demand. 

In the case of meat, the demand for special cuts of which 

there are but a few in each carcass, such as tenderloin steaks 

and sweetbreads, results in prices which are out of proportion 

b 



114 



NORMAL FEEDING AND FOOD ECONOMICS 



to the food value of these cuts. These unnatural prices react 
favorably upon the less desirable cuts, for they are sold at some- 
what lower rates. Other animal foods, such as game and shad-roe, 
are plentiful only at certain seasons of the year. Vegetables 
which are difficult or expensive to cultivate, such as mush- 
rooms, or are rare or transported long distances when out of 
season in a particular locality, bring high prices. 

The relation between supply and demand, and the lack of 
correspondence between food value and cost, is well illustrated 
by meat. Studies of the food value of the various cuts bring 
out the fact that the cost of protein — and meat is most 
valuable because of its protein content — increases roughly 
175 per cent, from the tougher cuts to the most expensive 
cuts of beef. 

The relative costs of the protein for 1000 Calories in the 
various cuts of beef are indicated in the following tables which 
may be used in conjunction with the table and charts on 
pages 143-146. 

Cost of Meat Required to Furnish One Pound of Protein and 
1000 Calories from Wholesale Cuts at Market Prices.^ ^ 









Retail 


Boneless 


Cost of pound 




Cost of 


Cost of 






price per 


meat in 


boneless 


pound 


1000 Cal- 


Wholesale cuts. 


pound, 


the cut, 


meat in cut, 


protein i 


n ories in 






cents. 


per cent. 


cents. 


cut, cents. cut, cents 


Fore shank . 




5 


59 56 


8.4 


50 


7 


Hind Shank 






5 


48 


84 


10.2 


63 


9 


Neck 






6 


84 


31 


7-1 


46 


5 


Flank . .. 






8 


99 


44 


8.0 


85 


3 


Plate . . 






8 


91 


23 


8.7 


82 


4 


Clod . . . 






10 


95 


18 


10.5 


63 


10 


Chuck . . 






II 


87 


99 


12.5 


84 


9 


Rump 






12 


79 


85 


15.0 


119 


8 


Round . 






15 


90 


39 


16.6 


lOI 


15 


Rib . . . 






18 


85 


56 


21.0 


171 


II 


Loin . 






22 


90 


23 


24.4 


188 


14 


Relative Fuel 


Valui 


iS of the 


Boneless Meat of the 


Wholesale Cuts.^ 2 














Pounds of 














boneless meat 


c 


'alories f 


urnished by 100 grams of 


Percentage distribu- 


required to 






boneless meat. 


tion of Calories. 


furnish 1000 


I 


^at X 9. 


Protein x 


4. Total. 


In fat. In protein. 


Calories. 


Flank . . 


514-4 


40.5 


554-9 


92.7 


7-3 


0.40 


Plate . . 


«7 


I 


46.0 


483 


I 


90 


5 


9 


5 


0.46 


Rib . . . 


365 


6 


54- 1 


419 


7 


87 


I 


12 


9 


0.52 


Rump 


350 


5 


55-3 


405 


8 


86 


4 


13 


6 


0-54 


Loin . 


339 


4 


57-4 


396 


8 


85 


5 


14 


5 


0.56 


Chuck . . 


247 


9 


65.8 


313 


7 


79 





21 





0.70 


Neck 


235 


I 


67.9 


303 





77 


6 


22 


4 


0-73 


Hind shank . 


186 


9 


71.0 


257 


9 


72 


5 


27 


5 


0.86 


Fore shank . 


179 


8 


73-9 


253 


7 


70 


9 


29 


I 


0.87 


Round 


176 


9 


73-6 


250 


5 


70 


6 


29 


4 


0.88 


Clod . . . 


161 


6 


73-5 


2^ 


35 


I 


68 


7 


31 


3 


0.94 



1 Hall and Emmett: Univ. of 111, Agri. Exp. Sta., 1912, Bull. 

2 See foot-note, page 109, 



158. 



COST OF FOOD 



115 



Cost of Lean and of Total Meat in the Various Retail Cuts at Market 



Retail cuts. 

Steaks : 

Porterhouse, hip-bone 

Porterhouse, regular 

Club steak 

Sirloin, butt-end 

Sirloin, round-bone 

Sirloin, double-bone 

Sirloin, hip-bone 

Flank steak . 

Round, first cut . 

Round, middle cut 

Round, last cut . 

Chuck, first cut . 

Chuck, last cut . 
Roasts : 

Prime ribs, first cut 

Prime ribs, last cut 

Chuck, 5th rib 

Rump 
Boiling and stewing pieces 

Round pot roast 

Shoulder clod 

Shoulder pot roast 

Rib ends . 

Brisket 

Navel . 

Flank stew 

Fore shank stew 

Neck . 
Soup bones: 

Round, knuckle 

Hind shank, middle cut 

Hind shank, hock 

Fore shank, knuckle 

Fore shank, middle cut 

Fore shank, end . 

The cost of lean beef is a rough index of the relative economy 
of steaks and roasts; in comparing boiUng and stewing meats, 
however, the cost of both fat and lean, gross meat, should 
have more weight because in the utiHzation pf these cuts the 
fat is usually incorporated with the lean in the form of meat 
loaf, hash, hashed meats (Hamburger steak), and corned beef. 
Since soup bones are of particular value for their flavoring 
material, their food value is not entirely comparable with the 
other portions of the carcass, as can be seen from the table. 
From the table we can see that the cheap cuts of meat actually 
furnish protein at a much lower price than the expensive cuts. 
It is to be remembered that in purchasing cheaper cuts of 
meat one often receives a larger proportion of connective 



Prices. 


1 2 






Diagram 
lumber, 
p. 145. 


Retail 

price per 

pound of 

cut, cents. 


Cost per 

pound of 

lean meat in 

cut, cents. 


Cost per 

pound of 

lean and fat 

meat in 

cut, cents. 


8 


25 


38.6 


28.9 


ID 


25 


40.2 


27.2 


i8 


20 


32.1 


22.6 


I 


20 


253 


20.6 


3 


20 


28.3 


21. I 


5 


20 


28.7 


22.7 


7 


20 


32.3 


24.2 


I 


I6 


19-3 


16.0 


2 


15 


17.0 


153 


6 


15 


173 


15-6 


14 


15 


193 


16.0 


2 


12 


18.3 


14. 1 


9 


12 


157 


131 


I 

4 


20 
l6 


40.5 
26.1 


22.9 
18.8 


I 


15 


22 ..8 


17-3 


I 


12 


19.4 


12.8 


i6 


lO 


11^6 


10. 1 


H 


ID 


12.3 


10.5 


II 


10 


143 


II. 6 


3 


• 8 


16.2 


9.2 


I 


8 


15.0 


8.7 


2 


7 


12.8 


7-7 


2 


7 


10.9 


71 


I 

15 


7 
6 


8.5 
8.5 


7.0 
7.0 


2 


5 


26.3 


12.5 


i8 
19 


5 
5 


7-5 
62.5 


6.3 
26.6 


2 


5 


17.2 


12.5 


4 
6 


5 
5 


12.5 

28.8 


9-4 
20.9 



1 Hall and Emmett: Univ. of 111. Agr. Exp. Sta., 1912, Bull. 158. 

2 See foot-note, page 109. 



116 NORMAL FEEDING AND FOOD ECONOMICS 

tissue with its incomplete protein, gelatin, than in the case of 
the more expensive cuts; this lowered food value is, however, 
more than compensated by the decreased cost of the complete 
protein. 

Fish may be used to vary the diet or as a source of relatively 
cheaper protein food; they are practically interchangeable with 
meat and are in general less expensive. 

In considering animal and vegetable food from an economic 
point of view, it is necessary to know whether the food-stufFs 
of the same kind which they contain are of equal value to the 
body; otherwise the apparently cheaper food may be in the 
end actually more expensive. Such considerations are par- 
ticularly important with regard to protein. Comparative 
studies of the digestibility of foods have shown that as ordi- 
narily prepared the protein of animal food is more completely 
absorbed than the protein of vegetables — meat protein, 91 
to 97 per cent.; vegetable proteins 80 to 85 per cent.; bread 
protein, 70 per cent.; rye protein, 40 to 76 per cent.; barley 
protein, corn protein, 61 to 83 per cent. The lower degree of 
absorption of vegetable proteins is due chiefly to the cellulose 
layer which surrounds the protein and prevents its digestion. 
A larger amount of total food in general must be ingested to 
obtain the same amount of protein from vegetable than from 
animal protein. In finely ground cereals and legumes, how- 
ever, the protein has been found to be as thoroughly digested 
as animal protein. Certain vegetable proteins are low in 
their content of the amino-acids necessary for growth and 
maintenance; but associated with these are other proteins which 
contain the necessary amino-acids. Consequently the natural 
mixture of proteins is more or less complete and unless par- 
ticular isolated or concentrated deficient proteins are involved, 
vegetable proteins may be used as the sole source of protein. 
That animal proteins are more eflftcient in satisfying the body 
needs than vegetable proteins has been found in studies of the 
comparative utilization of animal and vegetable proteins. A 
comparison of proteins of different origin on the basis of their 
availabiUty (biological value) to the body has shown that the 
different quantities of protein indicated when added to a carbo- 
hydrate diet will protect the body from protein loss after it 
has been reduced to a minimum on a purely carbohydrate diet: 

Grams. 

Meat protein 30 

Milk protein 31 

Rice protein 34 

Potato protein 38 

Bean protein 54 

Bread protein 76 

Indian corn protein 102 



ANIMAL VS. VEGETABLE FOOD 117 

It is evident, therefore, that naturally occurring protein 
mixtures of vegetable origin are not as efficient as animal 
protein and that larger quantities must be ingested not only 
because of their lower digestibility but also of their lower 
biological value. 

The economic question with regard to the use of proteins 
of animal and vegetable origin therefore resolves itself into 
which is cheaper, the ingestion of a large amount of vegetable 
protein or a smaller amount of animal protein. The answer 
must be tempered by a consideration of the increased activity 
of the body required to metabolize and excrete the excessive 
unavailable amino-acids of vegetable origin and of the pos- 
sible effect of such increased activity upon the general well- 
being of the body. It is impossible at present to answer the 
question. When our knowledge of the amino-acid content of 
proteins is sufficiently developed we may be able to furnish the 
deficient amino-acids of an economical diet with compara- 
tively small quantities of a more expensive protein. Even 
now we recognize the advisability of using a certain propor- 
tion of protein of animal origin with vegetable protein, for 
safety; there are very few diets which do not contain such 
protein, at least in the form of milk, eggs, or cheese. The 
inclusion of protein of animal origin in the diet is commendable 
from another point of view, for with the animal protein is 
purchased a certain amount of fat, a food of high caloric 
value. This addition of fat is desirable because it reduces 
the quantity of bulky carbohydrate food which must be 
ingested to meet the energy requirement of the body and also 
because it meets the need of a certain proportion of fat which 
would otherwise have to be purchased separately and added to 
the diet. 

A diet consisting largely of vegetables has been objected to 
on the ground that it is bulky; that a large quantity of food 
must be eaten in order to obtain sufficient protein, or else 
one must live on a low protein diet, for, with the exception 
of legumes and nuts, vegetable foods are relatively poor in 
protein. Since hunger is satisfied not so much by the quality 
of the food as by the quantity which is ingested, the appetite 
is in danger of being satisfied before sufficient material has 
been consumed to supply the protein requirement. For this 
reason and because vegetable proteins are less completely 
absorbed and less efficient in the body economy than animal 
protein a strictly vegetable diet is likely to be a low protein 
diet. 

It has been maintained by people who restrict their diet 
largely to vegetables, that they are able to utilize their food 



118 NORMAL FEEDING AND FOOD ECONOMICS 

more efficiently and that the body activities take place at a 
lower level than those who eat meat. Benedict has shown, 
however, that the basal metaboHsm of vegetarians is not 
essentially different from that of those living upon a mixed 
diet. It is possible that a vegetarian may be able to live on a 
low protein diet more readily than a man upon a high pro- 
tein, meat diet, because of the retarding effect of the indiges- 
tible cellulose upon the rate of digestion and of the absorp- 
tion of products of digestion of vegetable proteins. Experi- 
ments have shown that the admixture of indigestible material 
results in a more uniform rate of excretion of nitrogen in the 
urine than in the absence of such material; the inference is 
that the absorption from the intestine is likewise slower. 
On a vegetarian diet, then, instead of the rapid absorption of 
protein products of digestion and the disintegration of the 
excess characteristic of a high protein diet, the material is 
absorbed more slowly and the amino-acids are consequently 
more completely utilized for actual processes of repair and of 
growth. Proof of this fact has been presented in which a man 
was able to maintain nitrogen equilibrium on a lower plane of 
protein ingestion when food was taken in small amounts a 
number of times a day than when food was taken less often. 

In determining the value of a diet from an economic point 
of view consideration must be given to the quantity, propor- 
tion and kind of inorganic salts which it contains. While the 
average mixed diet contains a sufficient quantity of calcium, 
phosphorus and iron for the needs of the normal adult, the 
diet of children and nursing and pregnant women requires 
special attention in order that the mineral constituents be 
present in suitable proportions. A diet to be satisfactory with 
regard to its content of inorganic constituents must have the 
salts present in quantities which will meet the needs of the 
body and in such a form that the ash does not predominate 
potentially in acidic constituents — the same appUes to foods 
which are potentially basic but to a much less degree, for 
an excess of base is not as harmful as an excess of acid. 

From a consideration of the kinds and quantities of inor- 
ganic elements in foods it is evident that the vegetable foods 
and eggs are, in general, rich in calcium, iron and phosphorus 
and yield an alkaline ash (oatmeal yields an acid ash), while 
the ash of the egg is acid; meat is rich in iron and phosphorus 
and poor in calcium and has an acid ash; milk and cheese 
are rich in calcium and phosphorus, poor in iron and 3'ield an 
alkaline ash. Certain foods, particularly the prepared and 
purified products of both plant and animal origin, such as the 
fats and sugars, are very poor in salts. 



ANIMAL VS. VEGETABLE FOOD 119 

A diet in which vegetables and milk or cheese are the chief 
source of protein will therefore be predominately basic and 
contain, from a quantitative point of view, the most impor- 
tant inorganic constituents. In such a diet the low iron con- 
tent of milk or its protein products is compensated by the 
relatively high iron content of vegetables. A diet in which 
meat or eggs predominate will, on the other hand, tend to 
lower the alkaline reserve on the body, because of the acid ash, 
and meat will at the same time be deficient in calcium, while 
eggs will furnish this element in comparatively large amounts. 
Milk and cheese are therefore much more desirable not only 
as an economical source of animal protein but also for the 
salts contained in them. They can be included to advantage 
in a diet even when their cost is comparatively high. Eggs 
are next in order when the ash constituents are considered, and 
meat is the most expensive. 



PART II. 
FOODS. 



CHAPTER VI. 

INTRODUCTION— MILK. 

The preceding chapters have dealt with the digestion, 
absorption and utiHzation of food; and the factors which 
determine the quantity and nature of food required for the 
needs of the human body. The discussion was confined almost 
entirely to the materials which are the basic ingredients of food — 
protein, carbohydrate, fat, salts, water, and accessories. Oxy- 
gen is also a food; its presence is so general, however, that it 
is ordinarily omitted from a quantitative discussion of diet. 
Any food in the general sense is composed of one or more 
of these ingredients. One food may contain a preponderance of 
protein, another of fat, etc. For the discussion of the various 
foods, a basis of classification is necessary. A classification may 
be based upon the origin or composition of foods, or on the need 
which they supply. In the following chapters we classify 
foods according to their composition in terms of food-stufFs. 
For complex foods the particular food-stufF for which they are 
most valuable to the body determines the placement of them in 
the classification. Thus, we shall consider protein foods; fat 
foods; carbohydrate foods; and foods valuable for their salts, 
water, or accessory constituents, such as fruits, condiments, 
and beverages. A classification of this kind hot only empha- 
sizes the principal use of the food, but also aids in the search for 
foods that supply the elemental food factors; and it diflPers from 
the usual method of considering only the origin of foods in that 
there is no distinction recognized between vegetable and animal 
food. The dried legumes are placed with the protein-rich foods 
and certain animal products are placed with the fats. There is 
one food, however, which is difficult to classify under these 
circumstances but which is of sufficient importance to be 
considered alone, viz., milk, for it is the most complete food 
available. 



122 MILK 



MILK. 



Milk^ is a complex food— ^a product of the activities of the 
mammary gland — prepared for the nourishment of the grow- 
ing young. It is a whitish liquid with a characteristic odor and 
sweetish taste. The white color is due to the emulsified state 
of the fat and to the opalescence of the caseinogen solution. 
A slight yellowish tinge is imparted to milk, particularly when 
rich in fat, by certain coloring matters. This pigment appar- 
ently comes from the coloring constituents of plants (see 
p. 199) and consequently varies in amount with the diet. A 
lactochrome, which is similar to urochrome in urine, occurs 
in the whey of milk. 

The specific gravity of milk varies between 1.027 and 1.035. 
Two counteracting factors influence the specific gravity of 
milk — the fats, which tend to lower it, and the other soHd 
constituents, protein, carbohydrates and salts, all heavier than 
water, tend to increase it. The specific gravity is not neces- 
sarily a criterion of purity, for a skimmed, diluted milk may 
have the same specific gravity as fresh milk. Milk is an 
amphoteric Hquid and is approximately neutral in reaction, 
hydrogen-ion concentration 2.6 x io~^ gram molecules. Human 
milk is slightly more alkaline 0.6— i.i x io~^ The freezing- 
point of milk is —0.55° C. 

A microscopic examination of milk reveals the presence of 
fine droplets of emulsified fat, leukocytes, and bacteria, par- 
ticularly streptococci. Milk that has not been carefully 
handled will contain dirt, and in some cases pathogenic 
bacteria. Bacteria may come from the udder itself or from, 
the air. Leukocytes are normal constituents of milk that 
increase in number when the udder is diseased. With proper 
precautions milk which will contain very few bacteria (200 to 
500 per cubic centimeter) may be obtained from a healthy cow. 
The number of bacteria per cubic centimeter has been taken 
as a standard of purity. The following values are those 
recommended by the Commission on Milk Standards as the 
maximum for each grade. 

Number of Bacteria Permitted in the Various Grades of Milk. 

Bacteria count shall not exceed per 
cubic centimeters. 

After 
Before pasteurization 

Grade. pasteurization. at time of delivery. 

A 200,000 10,000 

B 1,000,000 50,000 

C +1,000,000 —50,000 

^ We will confine our present discussion largely to the milk of the cow. Unless 
otherwise designated the term milk refers to cow's milk. 



MILK 123 

Non-pathogenic bacteria have very little effect upon adults 
but appear to be detrimental to infants. It is essential, then, 
that infants receive a milk containing very few bacteria. For 
the adult a milk of low bacterial count is desirable because of 
the greater probability of the absence of pathogenic organisms. 

Chemical Properties. — Milk contains all of the food-stufFs 
necessary for the growing organism: protein, fats, carbo- 
hydrates, and salts are present in amounts best adapted to 
the young for which it is prepared. It is a most satisfactory 
dietary constituent in the regimen of the adult. Water is 
quantitatively the most important constituent of milk. It 
exists to the extent of from 80 to 90 per cent., the average 
being about 87 per cent. 

Milk may readily be separated into products which are 
particularly rich in one or more of its constituents. By grav- 
ity, or more rapidly by centrifugaHzation, the greater propor- 
tion of the fat may be removed as cream. Conglomeration of 
the fat droplets gives butter; coagulation with rennin or pre- 
cipitation with acid separates casein or caseinogen respec- 
tively from the other proteins, salts and lactose. 

The following table gives the percentage composition of 
milk and various milk products arranged in the order of their 
increasing fat content (Jurgenson). 

Milk and Its Products Arranged According to Their Increasing 

Fat Content. 

Fat, Protein, Carbohydrate, 

per cent. » per cent. per cent. 



Centrifuged milk 0.2 

Skim milk 0.6 

Buttermilk . 0.6 3 

Whole milk 1 

Rennin coagulated milk/ • • 3 • 5 3 

Curds 10. o II 

Cream, usual 15.0 3 

Cream, fat 20.0 3 

Cream, very fat 30 . o 3 

Butter 85.0 o 



8 4 

8 4 

7 4 

o 3 

o 4 

o 4 

o 4 

5 



Milk and Its Products Arranged According to the Protein Content. 

Protein, Fat, Carbohydrate, 

per cent. per cent. per cent. 

Whey 0.8 0.1 5.0 

Whole milk \ 

Rennin coagulated milk/ •••3-7 3-5 4-4 

Curds (cottage cheese) ....lo.o 11. o 3.0 

Cheese, fat 27.0 30.0 

Cheese, medium fat 35.0 10. o 

Cheese, skim milk 35-0 40 

Protein. — The proteins of milk constitute about 3 per cent, 
of the total weight or 25 per cent, of the solid constituents. 



124 MILK 

Of the three predominating proteins in milk, lactalbumin 
lactoglobulin and caseinogen, the latter presents the most 
characteristic properties. Caseinogen^ belongs to the class of 
conjugated proteins called phosphoproteins. It is an acid 
protein, insoluble in dilute acids and dissolved by alkalis. 
Neutral solutions of caseinogen are not coagulated by boiling 
but a peUicle is formed, such as is observed upon boiled milk. 
The flocculent precipitation observed in sour milk consists of 
caseinogen which has become insoluble in the acid (lactic) 
produced by the action of bacteria upon the lactose. The 
changes in the protein molecule are simple and appear to 
mvolve only processes such as occur in the precipitation of 
inorganic substances. Precipitated casein may be dissolved 
by the addition of an alkali. Water-soluble casein prepara- 
tions are of this nature. 

The phenomena of the coagulation of milk by rennin also 
concerns caseinogen. The transformations are more profound 
than those mentioned above for sour milk. In this case the case- 
inogen is split into two molecules of casein or perhaps into a 
soluble whey, albumose and casein. The calcium salts of casein 
are insoluble; in the presence of soluble calcium salts calcium 
caseinate is formed and the characteristic clot is produced. 
The coagulum formed holds by absorption or entanglement 
certain quantities of fat and lactose. A comparative study of 
cow's milk and human milk shows that the quantity of case- 
inogen is greater in cow's milk than in human milk. 

Lactalbumin and lactoglobulin have not been shown to 
differ materially from the albumins and globulins of blood 
serum. The albumin forms about 0.6 per cent, of the whole 
milk or 15 per cent, of the proteins, while the globulin exists 
only in traces. Minute traces of fibrin and a protein called 
opalisin have been detected. 

Fats. — ^The fat in milk is a mixture of several different fats, 
the more important of which are the triglycerides of palmitic, 
stearic, and oleic acids, and to a less extent of myristic, buty- 
ric, caproic, caprylic and capric acids. Fat is ^the most 
variable constituent of milk, the proportion may vary from 
25 to 2 per cent.; the average is between 3 and 4 per cent. 
Further discussion of the fats of milk will be found under 
butter, p. 198. It is also rich in fats with low melting-points; 
factors which tend toward increased digestibiHty. Milk fat 

1 There is a certain confusion in the use of the terms caseinogen, the protein 
existing in fresh milk, and casein, the product of the action of rennin upon casein- 
ogen. (HaUiburton: Jour. Physiol., 1900, ii, 448.) Certain authors, particularly 
the German writers, designate the protein of fresh milk as casein and the clot 
as paracasein. 



MILK 125 

exists normally in the form of a fine emulsion. The degree of 
emulsion of fat in milk differs with the various breeds. The 
greater availability of the fat from the milk of the Holstein 
cow over that of the Jersey cow is ascribed to the finer state 
of division of the fat of the former. The value of condensed 
milk in the feeding of some infants has been ascribed to the 
fact that such milks are "homogenized" and consequently the 
fat is very finely divided. 

Carbohydrates. — Lactose, or milk-sugar, the principal carbo- 
hydrate constituent of milk, is a specific product of the mam- 
mary gland. Chemically it is a disaccharide. Hydrolysis, as 
in digestion, yields a molecule each of galactose and glucose. 
Compared with cane-sugar from which it differs only in the 
arrangement of its atoms, lactose is not as sweet or as soluble. 
These properties account in part for the use of lactose as a 
vehicle for drugs and, the lack of sweetness particularly, for 
its use m diets which must have a high caloric value and 
still be completely assimilable. Lactose is dextrorotatory, has 
a strong reducing power and is not fermented by ordinary 
yeast. Alcohol and lactic acid are formed from it by the action 
of certain bacteria, chiefly Bacillus lactis acidi and yeast. In 
these processes lactose is first hydrolyzed into its mono- 
saccharide components and then transformed into alcohol or 
lactic acid, according to the organism concerned. The pro- 
duction of lactic acid commonly occurs in the souring of 
milk. Alcoholic fermentation is induced in the preparation of 
"koumyss" and "kefir." The quantity of lactose in cow's 
milk varies from 4 to 6 per cent, of the whole milk, the average 
being about 5 per cent., or 38 per cent, of the total soHds. 

Salts. — The salts, inorganic and organic, consist of combi- 
nations of calcium, magnesium, sodium, potassium, and iron 
with the acid radicles of hydrochloric, sulphuric, phosphoric 
and citric acids. In addition there are probably combinations 
of these substances with the proteins. The proportion and 
importance of the salts in milk will be considered later (p. 127). 

Besides their direct food value, particularly for bone forma- 
tion, the combinations of calcium and the phosphoric acid 
radicle, calcium phosphates are associated with the casein- 
ogen in its natural state and are concerned in the coagulation 
of milk by rennin. 

The modification of cow's milk for infants by dilution with 
water, lime water, etc., reduces the proportion of salts in the 
modified milk. Forbes suggests the use of whey for the dilu- 
tion of milk which permits the reduction of the quantity of 
caseinogen without reducing the proportion of the other con- 
stituents, particularly the salts. 



126 MILK 

The iron content of milk varies with the species. Cow's 
milk contains a half to a fifth as much as human milk; human 
milk, 1.6 to 1.7 milligram of Fe203 per liter; cow's milk 0.3 
to 0.7 milligram of Fe203 per liter. This marked difference 
indicates that children fed on cow's milk get much less iron 
than when fed on human milk; a difference which is increased 
when cow's milk is diluted with water. 

Citric acid is present in cow's milk to the extent of approx- 
imately 0.1 per cent., roughly three times as much as in human 
milk. 

Studies of the rate of growth of rats have demonstrated that 
there are in milk certain materials which belong to the group 
of accessory substances or vitamines. Milk contains both the 
**fat-soluble A'' and the *Vater-soluble B" to large degrees. 

The constituents of the milk of any species are qualitatively 
the same. Slight quantitative differences exist due to indi- 
viduaUty, the course of lactation, the change of seasons, and 
the time of milking, night or morning, the first milk drawn, 
or the last, etc. Variations in the diet have little effect upon the 
composition of milk. Although the composition of milk fat 
may be affected by feeding foreign fat; the fat tends to acquire 
the characteristics of the ingested fat. Milk of different species 
differs chiefly in amount rather than in kind of the constituents 
present. 

The composite milk of a herd of cows, or from a city dairy 
is quite uniform in composition, although showing slight 
seasonal variations. Protein and fat are higher in the autumn 
and winter than in the spring and summer. Lactose remains 
fairly constant throughout the year. Generally the pre- 
dominating breed of cow influences the percentage of fat. 
Individual variations within a given herd, however, have been 
shown to be as great as the variations between breeds of 
cows. The following table gives the composition of cow's 
milk. 

Composition of Milk. 

Water = 87.1 

Fat = 3.9 fCasdn =2.5 

{ Nitrogen compounds = 3.2 J Albumin = 0.7 



Milk = 100 



Solids = 12.9 
100.0 



[Carbon dioxide 
Gases"! Nitrogen 
(Oxygen 



Solids not fat = 9.0 
12.9 



3.2 



Milk-sugar = 5.1 

Ash (salts) = 0.7 

9.0 



Substances foreign to milk appear in it when fed to a lac- 
tating animal. Thus strong flavors occur in milk as the result 
of certain diets; the peculiar taste of milk when the cows begin 

^United States Public Health and Marine Hospital Service, 1900, Bull. 56, 



MILK 127 

to graze in the spring is due to certain foreign constituents 
derived from the green food which have been transferred to the 
milk. Drugs and narcotics have been shown to appear in 
milk following their ingestion. 

Variations in Composition.— Milk of different kinds of ani- 
mals show very striking variations in the proportions of their 
constituents. The accompanying table shows the composition 
of human and cow's milk. 



Human milk , 


Water. 

88.5 


Protein 
Caseinogen. 

1.2 


Albumin. 
0.5 


Fat. 

3-3 


Lactose. 
6.0 


Salts. 
0.2 


Cow's milk 


87.1 


30 


0.53 


3-7 


4.8 


0.7 



A consideration of this table, with its many differences and the 
favorable growth of all young, emphasizes the fact that there is 
an elaboration of milk best adapted to the young of the particular 
species. Milk of one species when fed to the young of another 
may, as we know is the case in infant feeding with cow's 
milk, prove deficient in one constituent and excessive in 
another and thus be entirely unsatisfactory. 

The adaptation of milk to the young of a species has been 
shown to be pertinent in the case of the inorganic constitu- 
ents as well as in the organic constituents. The similarity of 
the composition of the ash of the young and the ash of the 
milk has been shown by Bunge and others. The following 
table gives the ash constituents of the young and milk of the 
rabbit, dog, and man, and the milk of the cow. 

Comparison of the Composition of the Ash of Milk with that of the 
Newborn Young for Which it is Intended, 



Potassium (K2O). 
Sodium (NazO) . 
Calcium (CaO) . 
Mangesium (MgO) 
Iron (FeaOs) . . 
Phosphorus (P2O5) 
Chlorine (CI) 

It will be seen that the species which rapidly increases in 
weight, a milk is secreted with ash constituents that are quite 
similar to those of the young, while for the more slowly 
growing organisms, as man, there is a discrepancy between 
the two. 

Influence of Temperature. — Bacteria. — Milk when drawn 
from the mammary gland contains, in addition to the food-stuffs. 











Rabbit 




Puppy 


Human 




Cow's 


Rabbit's 


14 days 


Bitch's 


few 


milk. 


Infant. 


milk. 


milk. 


old. 


milk. 


hrs. ok 


35-2 


6.2 


22.1 


10. I 


10.8 


15.0 


II. I 


10.4 


8.1 


13-9 


7-9 


6.0 


8.8 


10.6 


14.8 


40.5 


20.0 


35-7 


350 


27.2 


295 


2.9 


1.5 


2.6 


2.2 


2.2 


1-5 


1.8 


0.18 


0.39 


0.04 


0.08 


0.23 


0.12 


o.7i 


21.3 


35-3 


24.8 


39-9 


41.9 


34-2 


39-4 


10.8 


4-3 


21.3 


5-4 


4-9 


16.9 


8.4 



128 MILK 

organisms and substances, such as leukocytes, bacteria, and 
enzymes. If raw milk be permitted to stand at ordinary tem- 
peratures, particularly when exposed to the air, physical and 
chemical transformations take place. These are chiefly bac- 
terial; changes caused by leukocytes and the enzymes secreted 
with the milk are of little practical importance. 

The bactericidal properties of milk prevent the initial rapid 
growth of bacteria. Raw milk exhibits, at room temperature, 
an apparent inhibition of bacterial growth; in some cases a 
destruction of bacteria has been demonstrated. The restrain- 
ing action of raw milk extends over a period of from 12 to 24 
hours; after this time a rapid multipHcation of bacteria takes 
place. This increase is retarded at low temperatures, 15° C. 
and below. When heated to 80° C. or above milk loses its 
power to restrain bacterial growth. There is a more pro- 
found change in the latter case, for such milk permits a rapid 
growth of the bacterial organisms. Heated milk may there- 
fore become more dangerous than unheated milk unless care is 
taken to prevent reinoculation of the heated product, otherwise 
a greater number, and perhaps more virulent types, of bacteria 
may develop than would have developed in unsterilized milk. 

The presence of pathogenic organisms in a heterogeneous 
milk supply, however, demands some means of kiUing them or 
restraining their growth, such as sterilization or pasteuriza- 
tion. In pasteurization milk is heated to 60° to 70° C. (140° 
to 160° F.) for from ten to twenty minutes. As the result of 
this treatment practically all of the bacteria are destroyed. 
Such a temperature does not affect the spores, hence milk 
must be cooled and kept at a temperature which will inhibit 
or restrain their development. Heating to a temperature of 
60° C. for twenty minutes has been shown to have Httle effect 
upon the germicidal power of milk or upon the enzymes 
present in it. Sterilization is the process of destroying all of 
the organisms present, both bacteria and their spores. Com- 
plete sterilization can only be accomplished by long-continued 
boihng or intermittent heating below the boiling-point. Such 
a procedure also destroys the enzymes and the germicidal 
property of milk. In both pasteurization and sterilization the 
water-soluble accessory substance is destroyed. 

Action of Bacteria. — Bacteria, which produce unusual and 
abnormal products, find their way into milk as the result of 
carelessness in handling. They cause alterations in the color, 
odor, and taste of milk. The formation of blue milk, or red 
milk, of slimy or ropy milk, and the development of a bitter 
taste are the result of bacterial action. Certain yeasts cause 
alcoholic fermentation. 



MILK 129 

Lactic acid is the most important product of non-pathogenic 
bacterial action in milk; it is the predominating substance formed 
in the souring of milk. With the accumulation of the lactic 
and other acids the reaction of milk changes from approx- 
imately neutral to distinctly acid. Caseinogen is insoluble in 
this medium as shown by its precipitation, ordinarily called 
curdHng. The precipitated caseinogen settles to the bottom 
of the liquid, leaving the **whey.'' Whey contains all of the 
constituents of milk except the caseinogen and a portion of 
the fat with the addition of lactic acid, the loss of some lac- 
tose, and the transformation of a portion of the protein into 
its cleavage products. The physical evidence of souring is often 
the secondary result of bacterial action, rather than the direct 
consequence. 

Action of Heat. — The first evidence of the effect of heat 
upon milk is the formation of a pellicle or skin upon its sur- 
face. If this skin is removed another immediately takes its 
place. An examination of this film shows it to consist chiefly 
of protein and fat. The evidence favors the view that the 
pelHcle consists of protein (caseinogen) which has entangled 
the fat, for solutions of caseinogen when heated give the 
same kind of film. Surface evaporation and fat facilitate the 
formation of the skin but are not essential. If the milk be 
slightly acid, such as following bacterial action, heat does not 
produce a film but coagulation occurs. It is the presence 
of a small quantity of acid which causes the coagulation of 
apparently fresh milk in the process of pasteurization. 

When milk is heated to between 60° and 70° C. most of the 
bacteria present in it are destroyed. Such heating has little 
effect upon the other constituents of milk. If the temperature 
be raised above 70° C, however, the composition, color, odor 
and taste are affected according to the extent of heating. 
The accessory substances or vitamines are at least in part, if 
not entirely, destroyed by heating.^ The caseinogen is appar- 
ently affected by boiling when judged from its retarded coagu- 
lation with rennin. Pure solutions of caseinogen are not 
affected by heating, hence the retardation of coagulation may be 
due in part to the altered state of a portion of the calcium salts 
which have probably been precipitated as tricalcium phosphate. 
Experimental evidence indicates that there is no change in the 
digestibihty of caseinogen as the result of heating, and it may 
even be an advantage for the curd if heated milk tends to be 
more flocculent than that of raw milk. The biological prop- 
erties of milk — enzymes, etc. — are destroyed by heating. 

^ The addition of orange or potato juice will tend to prevent the development 
of scurvy when pasteurized milk is used by infants, 

9 



130 MILK 

The albumins are coagulated in the process of heating. 
Studies on the change in the viscosity of milk when heated 
have shown that permanent coagulation takes place at 70° C. 
The Hberation of ammonia and of volatile sulphide, probably 
hydrogen sulphide, are indications of changes in the proteins. 
These last factors are probably partially concerned in the 
taste and odor of heated milk. If the boihng be sufficiently 
long continued, milk acquires a brownish color from the modi- 
fication of the milk-sugar, lactose. This change is similar to 
the browning of sugar or caramelization. The influence of heat 
upon the digestibility of milk will be considered later. 

Refrigeration of milk retards the growth of bacteria and 
the action of enzymes but these processes are not entirely 
inhibited. The changes in the composition of refrigerated 
milk are due principally to bacterial action. They consist in 
a gradual proteolysis or digestion of the casein, the fermenta- 
tion of lactose, and the hydrolysis of fat. Proteolytic changes 
in the albumin are due to enzyme action; such changes are 
negligible in the ordinary period during which milk is kept. 

Digestion of Milk. — The coagulation of the milk protein, 
caseinogen, through the action of rennin, is the distinctive 
difference between the digestion of milk and that of other 
substances. Practically all other proteins are ingested in a 
solid state. Milk when swallowed passes into the stomach 
which contains the acid gastric juice. Under such conditions 
we might expect the caseinogen to be precipitated. This is 
not the case, however, for it has been shown that milk is 
coagulated, clotted by the rennin, before acid precipitation 
takes place. The cause of this is to be found in the nature of 
milk, in its abiHty to absorb a considerable amount of acid 
without changing its reaction appreciably, and in the fact that 
the gastric juice is not secreted fast enough to furnish sufficient 
acid to precipitate the caseinogen before the rennin has trans- 
formed it into casein. 

The reason for the coagulation of milk before digestion is 
not clear. Milk can be digested completely in a test-tube 
without the formation of the insoluble casein. It may be 
that if the caseinogen were not coagulated, the milk would pass 
on into the intestine more rapidly than that organ could take 
care of it and digestive disturbances would result. Coagulated 
caseinogen must pass through the usual stages of gastric 
digestion; the intestinal juice continues and completes its 
digestion. 

The coagulation of milk apparently concerns but two of its 
constituents, the caseinogen and the calcium salts. Accord- 
ing to the views of Hammarsten, caseinogen is hydrolyzed 



MILK 131 

through the action of rennin into two constituents, soluble 
casein and a peptone-like substance called whey protein. Soluble 
casein unites with calcium ions (soluble calcium salts), form- 
ing the insoluble calcium compound usually called casein, or 
calcium caseinate. More recent work has failed to discover 
the formation of this peptone-like substance in the process of 
hydrolysis b}^ rennin. The present conception of the changes 
in the hydrolysis is the spUtting of the caseinogen into two 
equal molecules of casein, which, being insoluble in the pres- 
ence of soluble calcium salts precipitate out of solution, form- 
ing the clot. In the absence of soluble calcium salts hydrolysis 
occurs, but the formation of the insoluble clot does not take 
place until they are added. There is a tendency to ascribe to 
pepsin the changes we have assigned to rennin, i. e., to assume 
that rennin and pepsin are identical and the hydrolysis just 
described is the first step in the gastric digestion of caseinogen. 

The physical nature of the clot is influenced by the condi- 
tions under which it is produced. In the test-tube cow's milk 
gives a firm, tough, clot which finally contracts, squeezing out 
the whey. If the milk be agitated slightly, a fine flocculent 
precipitate is formed. This is probably the type of clot which 
is produced in the stomach rather than the tough clot usually 
described. The presence of fat influences the nature of the 
coagulum. Fat becomes entangled in the precipitated casein, 
causing it to form rather dense masses which show a tendency 
to coalesce in distinction from the flocculent, finely divided coag- 
ulum obtained with skimmed milk. This fact is of importance 
in the feeding of infants, and will be discussed later. Boiled 
milk is held to give a more flocculent clot than unboiled milk. 

Various methods are employed, particularly in the feeding 
of infants, to ensure a lively flocculent clot and to increase its 
digestibility, such as the addition of barley water, dilution 
with water or lime water, the addition of citrates, or heat- 
ing. The addition of cream and coagulation before eating 
(butter milk) also ensures a finer curd, but these methods are 
restricted to adults. 

The intestine completes the digestion of the milk. Here the 
proteoses, caseoses, are reduced to simpler complexes by the 
trypsin of the pancreatic juice and the erepsin of the intestinal 
juice. Erepsin has the abiUty of converting caseinogen into 
amino-acids, although it is unable to act on most other 
natural proteins. This is probably an important factor in 
digestion by infants who, it is afl&rmed, receive a part of the 
ingested milk from the stomach without its first being acted 
upon by the gastric juice. Lactose and the fats are first acted 
upon extensively in the intestines. 



CHAPTER VII. 
PROTEIN FOODS. 

The protein requirement of the human body is suppHed 
from both the animal and the vegetable kingdoms. A closer 
analysis of the facts shows the latter to be the ultimate source 
of protein; for, at least so far as our present knowledge extends, 
only the plant is able to synthetize this essential food-stuff 
from inorganic matter. With one or two exceptions, however, 
we find that protein predominates in animal foods and that the 
latter are the chief source of this food-stuff in the human diet. 

In our previous discussion we considered the need for protein, 
the general products of its digestion, the forms in which its 
decomposition products are excreted, and the quantity of 
protein necessary for the functioning of the body. These con- 
siderations have been confined, so far as possible, to protein in 
general. The consideration of the differences among proteins 
has been postponed until a discussion of* the various kinds of 
protein foods could be concluded. 

The various proteins in one organism differ from those in 
another. The proteins in the individual organism are also of 
different kinds. Even proteins of the same kind from various 
sources are different in composition. These differences are 
exhibited in the physical properties as well as in the chemical 
composition. The processes of metaboHsm are concerned with 
the utiHzation of these varied proteins for the maintenance of 
the supply of the various body proteins. 

A determination of the elements present in proteins shows 
them to consist of carbon, hydrogen, oxygen, nitrogen, and 
sulphur. These elements are combined to form amino-acids, 
the structural units of the protein. Phosphorus is also present 
in some proteins, while others contain traces of certain of the 
metallic elements, such as iron, copper, iodine, manganese, 
and zinc. A protein is, then, a combination of amino-acids as 
such, or in combination with certain non-protein substances, 
such as carbohydrates, lipins (fatty acids), purine bases, phos- 
phoric acid, etc. In digestion the protein molecule is split 
by hydrolytic cleavage into simpler complexes — proteoses and 
peptones; these in turn give rise to less complex compounds, 
peptides, and finally amino-acids. It is through studies of the 



PROTEIN FOODS 133 

products of these hydrolj^tic cleavages that we have gained our 
knowledge of the constitution of protein. 

Consideration of the kinds and quantities of amino-acids 
present in proteins of various kinds and from different sources 
is not only instructive but necessary, for recent investigations 
have indicated the importance of relative quantities of amino- 
acids in the diet. 

The table on page 134 gives the proportions of the different 
amino-acids obtained from certain proteins. It is important to 
remember that every protein food is composed of a number of 
proteins and that the mass of total food at any meal is seldom 
deficient in any particular amino-acid. 

The protein content of food is usually estimated from the 
amount of nitrogen contained in it by multiplying this value 
by 6.25. This calculation is based on the fact that the aver- 
age nitrogen content of protein is approximately 16 per cent. 
This procedure is not entirely correct, for in different kinds of 
protein variations from 15 to 18 per cent, of nitrogen have been 
observed. Vegetable proteins are particularly high in nitro- 
gen. The average for wheat protein is 17.55 P^^ cent., which 
would give a factor of 5.7 instead of 6.25. 

Another error in the use of the value 6.25 is due to the fact 
that not all nitrogen in a food is present as protein; a certain 
proportion is present as extractive nitrogen. Calculations of 
the protein content of foods based upon determinations of 
protein itself as compared with the calculated values for pro- 
tein (N X 6.25) show that on the latter basis the flesh of 
different animals contains various amounts of protein, wheras 
actually they differ but Httle in their percentage protein content. 

Protein. 

Determined 
Species. (N. x 6.25). by Janney.i 

Chicken 19.3 16.6 

Fish (halibut) 18.6 16.5 

Ox 21.6 16.6 

Rabbit 20-. 8 16.3 

Cat 21. 1 17.8 

Dog 20.2 17.4 

Man 19.7 16.4 

The body proteins differ from one another and from the 
food proteins. Some proteins are entirely lacking in certain 
amino-acids. In our discussion of the protein requirement 
(p. 70) we saw that the effect of the absence of partic- 
ular amino-acids from the protein molecule, when used as the 
sole source of protein, was in a failure to grow. In a previous 

^ Janney: Jour. Biol. Chem., 1916, xxv, 85. 



134 



PROTEIN FOODS 



11 


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Glycine .... 
Alanine .... 

Valine 

Leucine .... 
Phenyl alanine . . 
Tyrosine .... 

Serine 

Cystine .... 
Proline .... 
Oxyproline 
Aspartic acid . 
Glutamic acid 
Arginine .... 
Tryptophane . 
Lysine . 

Histidine .... 
Ammonia .... 



PROTEIN CLASSIFICATION 135 

chapter the inabihty of the body to synthetize protein and 
certain amino-acids was discussed (p. 99). The necessity 
for a Hberal supply of the different amino-acids in the form of a 
varied selection of proteins, and for a kind of digestion that 
converts these structural elements in protein into readily 
available substances either as the amino-acids or simple com- 
plexes of these is therefore evident. Such a variety is obtained 
in the ordinary mixed diet; in special diets it is a factor to be 
considered. The influence of the ingestion of proteins homol- 
ogous to those present in the body upon the minimum protein 
requirement has been discussed (p. 69). 

Proteins are not ordinarily distinguished by their amino-acid 
content, however, but chiefly by their physical properties. 
Differences in chemical composition are, however, the basis of 
distinction between the members of one group — the conjugated 
proteins.^ 

The following outline of the kinds of proteins and their 
characteristics, the classification adopted by the American 
Physiological Society and the American Society of Biological 
Chemists, will be adhered to in our discussion. This classi- 
fication differs from that of the English societies in a few 
instances; in most matters they are essentially identical. 

I. Simple Proteins. — Protein substances which yield only 
a-amino-acids or their derivatives on hydrolysis: 

(a) Albumins.2 — Soluble in pure water and coagulable by 
heat. Albumins are present in all cells and in the important 
fluids of the body. Ovalbumin is the predominating protein 
of egg white. Other important albumins are serum-albumin 
present in blood plasma, lymph and other body fluids; lact- 
albumin of milk; the vegetable albumins, leucosin of wheat, 
and legumeKn of the pea. 

(b) Globulins. — GlobuHns are insoluble in pure water but 
soluble in neutral solutions of salts of strong bases with strong 
acids. GlobuHns are present in blood, serum globuHn; egg, ovo- 

^ The terms protein and proteid are often used together. The present-day 
German writers use the word protein to designate simple albuminous substances, 
and proteid for combinations with other complexes. The simple proteins and 
the conjugated proteins of the American classification are proteins and proteids 
respectively in the German classification. A distinction is sometimes made 
between protein and proteid among English-speaking writers. Proteid designates 
definite chemical compounds, or isolated albuminous substances (our proteins), 
while protein is used to denote the mixture of proteids in a food, the measure of 
which is the quantity of nitrogen which the food yields upon analysis times 
6.25, the average percentage of nitrogen in pure proteid. Protein has been 
adopted by English-speaking scientists as the generic term for the class of sub- 
stances which we are discussing — and we will use this term in that sense. 

^ A distinction is sometimes made between the pure individual substances 
albumw and a mixture of proteins occurring naturally together, or aXhwcaen, as 
the white of egg. The term albumen is used very Httle and is now practically 
restricted to the expression "egg albumen." 



136 PROTEIN FOODS 

globulin; milk, lactglobulin; seeds, edestin (hemp seed); 
legumin (pea). 

(c) Glutelins. — Glutelins are simple proteins insoluble in all 
neutral solvents but readily soluble in very dilute acids and 
alkalies, e. g., the vegetable protein, glutenin, from wheat. 

(d) Alcohol Soluble Proteins (Prolamines). — Simple proteins 
soluble in 70 to 80 per cent, alcohol, insoluble in water, 
absolute alcohol, and other neutral solvents, e. g., zein, corn; 
ghadin, wheat; hordein, barley. 

Gluten, readily obtained from wheat flour by washing away 
the starch, albumin, etc., is a mixture of members of the last 
two classes of proteins, glutenin and gliadin. 

(e) Albuminoids. — Simple proteins possessing a similar struc- 
ture to those already mentioned, but characterized by a pro- 
nounced insolubiUty in all neutral solvents. The proteins 
concerned in the framework of the body are the most impor- 
tant members of this group, e. g., elastin and collagen; con- 
nective tissue; keratin — hair, nails and horn; and fibroin from 
silk. Acids or prolonged boiling with water convert collagen 
into gelatin. Gelatin is not, however, classed as an albu- 
minoid. The EngUsh nomenclature aptly designates the 
albuminoids as scleroproteins. 

(/) Histones. — Soluble in water and insoluble in very dilute 
ammonia and, in the absence of ammonium salts, insoluble 
even in excess of ammonia; yield precipitates with solutions 
of other proteins and a coagulum on heating which is easily 
soluble in very dilute acids. On hydrolysis they yield a large 
number of amino-acids among which the basic ones predom- 
inate. In short, histones are basic proteins which stand 
between protamines and true proteins, e. g., globin, one of the 
constituents if hemoglobin; thymus histone and scombrone 
from sperm. 

(g) Protamines. — Simpler polypeptides than the proteins 
included in the preceding groups. They are soluble in water, 
uncoagulable by heat, have the property of precipitating 
aqueous solutions of other proteins, possess strong basic prop- 
erties and form stable salts with strong mineral acids. They 
yield comparatively few amino-acids, among which the basic 
amino-acids predominate. These proteins are obtained from 
spermatozoa in which they occur in combination with nucleic 
acid. The various members of this class are designated accord- 
ing to the animal from which they are obtained, as salmin 
from the salmon sperm; sturin from mackerel sperm, etc. 

II. Conjugated Proteins. — Substances which contain the 
protein molecule united to some other molecule or molecules 
otherwise than as a salt. 



PROTEIN CLASSIFICATION 137 

(a) Nucleoproteins. — Compounds of one or more protein 
molecules with nucleic acid. This type of protein is the prin- 
cipal constituent of cell nuclei and is found in practically all 
protein-rich foods. Milk and the white of egg are important 
exceptions. Nucleoprotein is a very complex substance yield- 
ing upon hydrolysis first protein and nuclein. Nuclein then 
disintegrates into a second protein, usually basic, as histone 
or protamine, and nucleic acid. Nucleic acid may consist of 
one or more combinations of phosphoric acid, carbohydrate, 
and one of the purine or pyrimidine bases called nucleotids. 
Upon hydrolysis of a combination of nucleotids, the various 
nucleotids result. The phosphoric acid is next spKt off from 
the nucleotids leaving the purine- or pyrimidine-carbohydrate 
complex, nucleosid, which finally yields carbohydrate and the 
base. The following scheme shows the disintegration of 
nucleoprotein: 

Nucleoprotein 



protein nuclein 
/\ 
/ \. 
protein nucleic acid 

(nucleotids) 

. / \ 
phosphoric acid nucleosid 

/ \ 
carbohydrate purine base 

pyrimidine base 

The purine bases from nucleoprotein are the chief source of 
the uric acid which appears in the urine of mammals. 

(b) Glycoproteins. — Compounds of the protein molecule with 
a substance or substances containing a carbohydrate group 
other than a nucleic acid, e. g., mucins an,d mucoids (osseo- 
mucoid from bone, tendomucoid from tendon, ichthulin from 
carp eggs, heHcoprotein from snail). 

(c) Phosphoproteins. — Compounds of the protein molecule 
with some, as yet undefined, phosphorus-containing substances 
other than a nucleic acid or lecithin, e. g., casein from milk, 
ovovitellin from egg yolk. 

(d) Hemoglobins. — Compounds of the protein molecule with 
hematin, or some similar substance, e. g., hemoglobin from red 
blood cells, hemocyanin from blood of invertebrates. 

(e) Lecithoproteins. — Compounds of the protein molecule 
with lecithin. 



138 PROTEIN FOODS 

III. Derived Proteins. — ^A. Primary Protein Derivatives. — 
Derivatives of the protein molecule apparently formed through 
hydrolytic changes which involve only slight alteration of the 
protein molecule. 

{a) Proteins. — Insoluble products which apparently result 
from the incipient action of water, very dilute acids or 
enzymes, e. g., myosan from myosin, edestan from edestin. 

(b) Metaproteins. — Products of the further action of acids 
and alkaUs whereby the molecule is so far altered as to form 
products soluble in very weak acids and alkalis but insoluble 
in neutral fluids, e. g., acid metaprotein (acid albuminate), 
alkali metaprotein (alkali albuminate). 

(c) Coagulated Proteins. — Insoluble products which result 
from (i) the action of heat on their solutions, or (2) the action 
of alcohol on the protein. 

B. Secondary Protein Derivatives. — Products of the further 
hydrol3^tic cleavage of the protein molecule. 

(a) Proteoses. — Soluble in water, non-coagulable by heat, 
and precipitated by saturating their solutions with ammo- 
nium — or zinc sulphate, e. g., protoproteose, deuteroproteose. 

{h) Peptones. — Soluble in water, non-coagulable by heat, but 
not precipitated by saturating their solutions with ammonium 
sulphate, e. g., antipeptone, amphopeptone. 

(c) Peptides. — Definitely characterized combinations of two 
or more amino-acids, the carboxyl group of one being united 
with the amino group of the other with the elimination of a 
molecule of water, e. g., dipeptides, tripeptides, tetrapeptides, 
pentapeptides. 

Influence of Heat. — The effect of heat upon simple proteins is 
to cause them to coagulate. Such changes are continually occur- 
ring in the preparation of food for the table. The boiling of an 
egg, or the roasting of meat is accompanied by the coagula- 
tion of the protein, and it is to a large extent the coagulation 
of the protein among expanded gas bubbles which keeps bread 
and cake *' light.'' Two changes take place in the coagu- 
lation of protein: there is first a reaction between the hot 
water and the protein as the result of which the protein loses 
certain of its characteristic properties, such as solubility, i. e., 
the protein is denatured. Secondly, the altered particles of 
protein agglutinate into visible masses or coagula which 
separate from the solution. When the protein is held in the 
meshes of connective tissue, etc., the denatured protein shrinks 
or contracts so that water and dissolved salts are squeezed 
out. This phenomenon is called syneresis. The accumulation 
of beef juice around a roast when cut on the platter is the 
result of syneresis. The presence of acid and small quantities 



EFFECT OF LOW TEMPERATURES 139 

of salt facilitates the coagulation of protein. An excess of acid 
or alkali results in a solution of the protein and prevents 
coagulation. 

Certain proteins of the albuminoid class, such as collagen, 
are readily hydrolyzed (rendered soluble) particularly so in 
the presence of small quantities of acid. The long-continued 
cooking (usually just below the boiling-point) of tough cuts 
of meat accomplishes the hydrolysis of the connective tissue 
(rich in collagen) which tends to free the muscle fibers and 
permit their ready separation, i. e., makes the meat tender. 
The use of veal for soup stock and the ease with which the 
fibers of fish are separated is due to the large proportion of 
easily hydrolyzed connective tissue which they contain. Acid 
facilitates hydrolysis; it also tends to cause protein material 
to swell. The value of acid in cooking fish and tough meat is 
then self-evident. 

Protein combines with both acid radicles and basic radicles 
to form protein salts; the insoluble curd formed in the coagu- 
lation of milk occurs because the calcium salt of casein is 
insoluble in water; the sodium or potassium salts are soluble, 
and it is in this form that certain casein preparations are 
placed on the market. Certain proteins of the legumes form 
insoluble calcium and magnesium salts, which is the reason 
for the objection to the use of hard water in preparing legumes 
for the table. The use of egg white, etc., as an antidote for 
poisons is due to the insoluble salts which are formed by the 
protein with the heavy metals. 

Effect of Low Temperatures. — Low temperatures have no 
direct effect upon protein. Its properties may be altered, 
however, as the result of changes produced in the medium in 
which it is suspended. The crystallization of the intracellular 
water results in a concentration of the salts. This causes the 
precipitation of some proteins and the solution of others. 
Upon the return to the normal temperature the original state 
is restored. Long-continued low temperatures produce a 
change in the precipitated proteins so that they will not 
redissolve. The change just noted has been shown to occur 
in plants. 

During refrigeration protein food-stufFs undergo consider- 
able modification as the result of predominant enzyme action, 
autolysis, rather than of bacterial action which shares in the 
transformation at room and body temperatures. Low tem- 
peratures inhibit both bacterial and enzyme action, the former 
more than the latter, however. The changes which occur at 
low temperatures are analogous to those which take place 
in aseptic or sterile tissues, either in the body or out of it. 



140 PROTEIN- FOODS 

The "ripening" of flesh is due to these autolytic changes 
brought about by the intracellular enzymes. The action of 
the intracellular proteases is quite similar to that of the diges- 
tive enzymes, particularly trypsin. Protein passes gradually 
through the various stages of proteolytic digestion, finally 
yielding amino-acids. Examination of refrigerated meat, for 
instance, shows an increase in the quantity of water-soluble 
proteins, indicating a partial digestion. Other enzymes pro- 
duce changes in the fats and carbohydrate. The changes 
which result in foods preserved with certain chemical sub- 
stances, without the use of heat, are the result of autolysis. 

Bacterial growth is not entirely checked at comparatively 
low temperatures and changes undoubtedly occur as the 
result of their action. At higher temperatures, room temper- 
ature and above, the activities of bacteria increase. The prod- 
ucts of their action on proteins are in part similar to those 
produced in enzymatic digestion. The harmful effects of 
bacteria from a dietary point of view are not in the bacteria 
themselves so much as in the products (ptomaines) produced 
in the food, protein, during their growth. These substances 
are produced by non-pathogenic as well as by pathogenic 
organisms. The ptomaines are soluble basic substances closely 
related to the amino-acids; not all are toxic. 

The changes which proteins undergo in the course of diges- 
tion and absorption have already been discussed (p. 34). 
The rate with which they are made available for absorption 
depends upon their physical properties, whether they are in 
solution or solid, dense or finely divided, will imbibe water 
easily or with difficulty; and upon their chemical properties, 
such as acidic or basic, complex or simple. Preparation of 
food for use is often accompanied by change in the digest- 
ibility as well as in the availability of the food-stuffs. This is 
particularly true with regard to protein. The total available 
quantity of the protein is often increased in the course of 
preparation. The effect of grinding vegetable food-stuffs very 
fine is to increase their total digestibihty. The influence of 
heat upon the connective tissue of animal food-stuff is to 
cause a partial conversion of the collagen into gelatin; hence 
the ease of digestion is increased. In vegetable food-stuffs 
the indigestible cellulose structure is ruptured through the 
combined action of heat and water, thus promoting the action 
of the digestive enz3^mes upon the contained protein and 
carbohydrates. 



CHAPTER VIII. 
MEAT« OR FLESH FOOD. 

The dietary value of meat is due chiefly to its protein 
content. It contains in addition a varying quantity of lipin or 
fat, a small amount of carbohydrate, salts, and certain nitrog- 
enous derivatives related to the proteins called extractives. 
The palatability, variety, ease with which the flavor may be 
modified, facility of preparation, concentration of protein, and 
digestibility are factors which have made meat the most 
important protein of the adult human dietary. The fact that 
the proteins of meat are of the same type as those of the body 
would seem to indicate a possibly greater adaptability to the 
needs of the human organism than the vegetable proteins, for 
instance. There are no facts to show, however, that a suit- 
able mixture of vegetable proteins is not just as satisfactory 
as the animal proteins. The dietary and economic advantages 
and disadvantages of these two types of diet have been dis- 
cussed (p. ii6). 

Meat is derived almost entirely from the skeletal or striated 
muscles. Such muscles are composed of fibrils enclosed in 
sheaths known as sarcolemma (fibers) and bound together in the 
form of bundles by connective tissue. The fibers terminate in 
bundles of white fibrous connective tissue, the tendons, by 
means of which they are attached to the bones. Embedded 
in the connective tissue of the muscle bundles are cells more 
or less rich in fat, while between the various muscles compara- 
tively large masses of fatty tissues are found. Living muscle 
is practically neutral in reaction, but after <;leath lactic acid is 
formed and the reaction rapidly changes to acid. An. alkaline 
reaction in meat is an indication of putrefaction. 

The important proteins of muscle plasma are myogen (a 
globulin) which predominates, and myosin. After death these 
proteins become coagulated to form the muscle clot;^ this is 
the form in which the greater portion of the protein of meat 
exists. Immediately after death autolytic changes commence 
with the formation of lactic acid and protein digestion prod- 
ucts and are attended by an increase in the quantity of soluble 
proteins. These are the processes concerned in "ripening." 

^ Myosin is the name given to muscle clot by some investigators. 



142 MEAT OR FLESH FOOD 

The connective tissue contains a large percentage of the 
albuminoid collagen, which is a source of gelatin — the base of 
the jelly of cooked meat. The flesh of young animals, as veal 
and lamb, is particularly rich in connective tissue and their 
bones in collagen. The readiness with which meat from such 
animals yields gelatin makes it valuable as the basis of 
soup. Fish are also rich in gelatin-yielding tissues. Blood 
remaining in the capillaries and bloodvessels and in the blood 
plasma surrounding the cells, contains serum albumin, globulin, 
fibrin, etc. 

The hemoglobin in muscle and the residual blood gives 
meat its red color. The identity of the coloring substance 
in blood and in muscle is not generally admitted, although 
the close relation is acknowledged. The quantity of hemo- 
globin varies; it is greatest in muscles concerned in long- 
continued and powerful contractions and least in the more 
passive muscles. The dark and light meat of the birds 
show this relation. Certain species, as the rabbit, are poor in 
hemoglobin. The muscle of the young of most species is low 
in hemoglobin, hence their light color. The decided red color 
of meat preserved with nitrates appears to be due to the pres- 
ence of nitrous oxide hemoglobin. 

The small amount of glycogen normally present in muscle is 
almost entirely changed to glucose after death. The com- 
paratively large quantity of glycogen in fresh horse meat is 
one of its distinguishing characteristics. Fat varies in quan- 
tity, kind, and color with the condition of the animal, the 
food ingested, and the cut (portion of the carcass). 

Flavor in meat is due to the presence of the extractives — 
substances soluble in water, alcohol, or ether. In addition to 
the carbohydrates and fat just mentioned these include cer- 
tain non-protein, nitrogenous constituents, such as creatin, 
xanthin, hypoxanthin, inosin, etc.; the latter are the chief 
source of the exogenous uric acid. It is the latter extractives 
which the gouty patient should avoid and to which vege- 
tarians and certain food cults object, holding them to be waste 
products and a burden to the excretory system. 

The presence of purine compounds in the diet under certain 
pathological conditions, such as gout, is objectionable. It is 
important to know, therefore, the relative quantity of these 
substances in various foods. A table giving the purine contents 
of various kinds of flesh and of certain other foods will be found 
in a subsequent discussion of diet in disease. 

Meat often contains certain substances characteristic of the 
food ingested which gives to it the flavor so prized by epicures: 
these are particularly evident in game. 



COMPOSITION OF MEAT 



143 



Flesh or meat is ordinarily composed of about three-fourths 
water, but there is less water in fat than in lean meat and Hke- 
wise in old than in young animals. In the ash of muscle the 
salts of potassium and phosphoric acid predominate. Traces 
of sodium, calcium, magnesium, iron, sulphur, and chlorine 
are also found. The following table gives the approximate 
proportions in which the inorganic constituents occur in meat: 



Composition of the Ash of Typical Flesh Foods. 



Beef, lean . 
Veal, lean 
Lamb, med- 
ium fat 
Pork, lean 
Poultry 
Fish . . 



CaO. 
O.OII 
0.16 

0.0039 
0.012 
0.015 
0.03 



MgO. 
0.04 
0.045 

0.04 
0.046 
0.06 
0.04 



K2O. 
0.42 
0.46 

0.29 

0-34 
0.56 
0.40 



NaaO. 
0.09 
0.12 



0.093 
0.13 
0.13 
1.30 



P2O5. 
0.50 
0.50 

0.42 

0.45 
0.58 
0.40 



CI. 
0.05 
0.07 

O. 12 
0.05 
0.06 
2.40 



s. 

0.20 
0.23 

0.23 
0.20 
0.216 
0.22 



Fe. 

o . 0038 



o . 0003 



PER 
CENT 



60 



W5 



30 



eo 



10 



3C 

5 PER 
CCfM1 

















~ 






^ 








^^ 


^^ 








\ 

\ 

\ 






-^^ 








50 




y 


■"^ 














/ 
/ 
/ 
/ 


X 
X 
X 
X 
X 










30 
20 
10 




: \ 
: \ 








^X 

X 

^x 

X 








\ 
\ 


/ 
/ 






'^, 


" ^ 






/ 








•* 














VISIBLE rA1 
BONE 












J 






1 




^ 



Fig. 3. — Percentages of lean, visible fat and bone in the straight wholesale cuts.^ 
(Courtesy of the Illinois Agricultural Experiment Station.) 

Some meats when purchased contain inedible parts, such as 
bone, the exterior portions of the carcass, large bloodvessels, 
connective tissue, gristle, and tendon. In considering a par- 
ticular piece of meat from a purely dietary point of view 
allowance should be made in the calculation for the waste 



Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 



144 



MEAT OR FLESH FOOD 



which these portions represent. From an economic stand- 
point it is essential to know the quantity of edible material 
likely to be derived from a given piece of meat. Fig. 3 gives 
the percentages of lean, visible fat, and bone in the straight 
wholesale cuts of beef. 

An inspection of this chart reveals in general an inverse 
relation between the percentage of lean meat and that of visible 
fat; the relative weight of bone is more variable. 

The proportions of the various food-stuffs in meat varies 
according to the kind of animal and the portion of the anat- 
omy from which it is obtained. The same "cut" of meat 
from different animals varies according to its age and 
nutritive condition. The relative differences in the protein 
content of the various cuts of beef is shown in the following 
chart (Fig. 4) prepared by Hall and Emmett, which gives the 
percentage of the total protein in the boneless meat of whole- 
sale cuts. 



z 

< 

PER J 
CENT 




SOLUBLE PROTEIN 
TOTAL PROTEIN 



'I 

,CCNT 



i7 



Fig. 4. — Percentages of total and soluble protein in the boneless meat of the 
wholesale cuts.^ (Courtesy of the Illinois Agricultural Experiment Station.) 



The curves show a relative increase in the quantity of pro- 
tein as we consider the cuts from the left to right. Calcu- 
lated on the basis of the dry, moisture-free, substance an even 
greater increase is found, because the cuts on the right con- 

1 Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 



COMPOSITION OF MEAT 



145 




H/ND QUARTER 



1 


POUA/£> 


A 


Rump 


h 


1 Pomp 


I 


Round: ramp S shank off- 


1 


£ Round sfcak, first cuf- 


> 


3- /J Round steaks. 


$ 


!4 Pound steak, /asf cut. 




J5 Knuck/e .soup bone 




16 Pot roast 




H/nd 3hank. 




17. /8 3oup bones 




19 fiock 3oup bom 




Loin 




1 Buff- end sirfoin Jifeok. 




Z Wedge- bone s/rfo/n steak. 




3, A Round -bone 


^ 


5,6 DoubJe-bone 




7 fi/p-bone 


^ 


a h/p-bone. Porterhouse ^feak 
9-J5 Pejufc/r 


T 


>i 


IG-18 Club ^/eaks. 


K 


rLAATK 




t Flank steak 




a Slew. 



rORZ QUARTER 



R/B 




1 


nth Sk ie.th P/t> roost 


£.. 


9U> 3 lOth •' 


3 


1*± & Qth " 


4 


Qih - ~ 


CHUCh( 




1 


3ti P/b roast-. 


£-9 


Chuck steaks 


10 -D Pot roasts. 


14- 


Clod 


15 


Neck 


Plate. 




1 


3n3kef 


t 


Navet 


3,4- 


Rib ends 


FOFiE .SHA/iH 


1 


3few. 


a 


Knuckle, soup horn. 


3-G 


3oup bones. 



RETAIL ' CUT3 • OF- BEEF 



Fig. 5. — Method of cutting the three sides, showing retail cuts. (Courtesy of 
the IlHnois Agricultural Experiment Station.) 

Composition of Typical Flesh Foods.^ 

Protein 

Water, N x 6.25, Fat, Ash, Fuel value 

percent. percent. percent. percent. per pound. 

70.0 21.3 7.9 I. I 709 

70.3 21.2 8.0 I.O 711 

63.9 19.2 16.5 I.I 1022 

60.0 25.0 14.4 1.3 1042 

7 19.3 16.3 1.0 1016 

7 172 0.3 1.2 324 

Bull. 28, revised. 



Beef 

Veal 

Lamb 

Pork 

Poultry 63 

Fish 81 



U. S. Dept. Agr., Office Exp. Sta., 1906 



10 



ible. 


Insoluble. 


Total. 


42 


15-56 


16.98 


81 


14 


88 


16.69 


08 


14 


42 


16.50 


59 


14 


67 


16.26 


65 


13 


94 


15 -59 


47 


13 


40 


14.87 


37 


II 


59 


12.96 


26 


II 


30 


12.56 


20 


II 


12 


12.32 


83 


9 


76 


IO-59 


66 


8 


78 


9.44 



146 MEAT OR FLESH FOOD 

tain more lean and less fat and also because the lean meat 
has a greater water content. When the fat is excluded from 
consideration, the protein content of the various cuts is quite 
similar. In other words, the difference in the various cuts 
of beef is due to the varying quantities of fat and water. 
The differences among the percentages of the food-stuffs in 
the various kinds of meat are likewise due to similar varia- 
tions; this is shown in the accompanying table taken from a 
compilation of analyses by Atwater and Bryant. 

Percentages of Water-soluble, Insoluble, and Total Protein in 
THE Boneless Meat of the Wholesale Cuts.^ 

Wholesale cuts. So] 

Fore shank i 

Clod I 

Round 2 

Hind shank i 

Neck I 

Chuck I 

Loin I 

Rump I 

Rib I 

Plate o 

Flank 0.66 

Fig. 5 enables one to locate the portion of the animal under 
consideration. 

Effect of Heat on Meat. — Cooking. — The objects to be 
accompHshed by cooking meat are the improvement of its 
flavor and appearance; the modification of its texture, and 
the destruction of parasites and bacteria. Digestibility of 
protein is not increased by cooking; it is diminished in many 
cases. Such changes as the hydrolysis of connective tissue 
and comminution increase the ease of digestion. 

The flavor acquired by meat through cooking is due to 
changes, probably oxidative, in the soluble, extractive, por- 
tions of the flesh and in the fats.^ A study of the development 
of flavor in which the juices were separated from the insoluble 
portions (fiber) of beef showed the flavors to develop in the 
juice more than in the residue, and in the extract not coagu- 
lable by heat more than in the coagulable portion. A study of 
the effect of various temperatures showed the flavor to develop 
most at temperatures above 100° C; below this the taste is 
more or less insipid. The pronounced flavors developed by dry 
heat are thought to be due to the higher temperatures attained. 
The fat of meat when heated suflRciently high also gives rise to 
characteristic flavors. 

^Hall and Emmett: Univ. 111. Agr. Exp. Sta., Bull. 158, 1912. 
^Grindley and Emmett: U. S. Dept. Agr., Office Exp. Sta., Bull. 162. 



EFFECT OF HEAT 147 

The appearance of meat is also improved by cooking as the 
result of the coagulation of the proteins and the transforma- 
tions in the hemoglobin whereby the more or less objectionable 
reddish-purple color of uncooked, raw meat is changed to the 
light red or brown color of cooked meat. Those changes in 
appearance are most evident in roast beef and are enhanced 
by the crisp outer layer of fat. 

Three methods are employed to make a piece of meat ten- 
der: (i) Cooking for a long time at low temperature; simmering 
at approximately 80° C. (this is sometimes incorrectly desig- 
nated boiHng) whereby the insoluble collagen of the connec- 
tive tissue is changed to gelatin, thus loosening the libers. 

(2) The mechanical separation of the fiber from the connec- 
tive tissue by scraping, a tedious process practised in the 
preparation of a readily digestible protein food for the sick. 

(3) Grinding, mincing, or pounding by which means the con- 
nective tissue is mechanically severed. 

In the cooking of meat two general methods are employed 
which differ in the mode of application of the heat: {a) The 
direct appHcation of radiant heat, as in roasting and broiKng 
and {h) the application of heat through the medium of a liquid, 
as boiHng in water and frying in deep fat. 

Roasting and baking are used synonymously by the aver- 
age cook. A distinction should be made, however, between 
so-called roasting or baking and true roasting. ^ True roasting 
is cooking by radiated heat from glowing coals, but one side 
of the food being exposed to the heat at a time. Broiling is 
essentially the same in principle as true roasting, but the 
food is brought into direct contact with radiant heat. The 
length of time of the two processes differ, for a thinner cut of 
meat is used for broiling. Baking is cooking in a ventilated 
oven. Although frying in deep fat belongs properly, as indi- 
cated, to the indirect method of cooking, the results obtained 
are more like those obtained with the direct application of dry 
heat. 

The changes produced in meat by cooking, aside from slight 
differences in flavor, are of two kinds, those characteristic of 
roasting and of boiHng. Combinations of these, as in pot roast- 
ing, so admirably adapted to the preparation of tough, cheap 
cuts, yield some of the advantages of each method. In this case 
the tenderness of boiled meat is combined with the flavor of 
roasted meat. Grindley and Emmett have shown the effect 
of roasting (baking) to be similar to that produced in broiHng, 
parboiling, sauteing, and frying. 

^ Bevier and Spraguc: Univ. 111. Agr. Exp. Sta., Circular 71, 1903. 



148 MEAT OR FLESH FOOD 

Roasting is practised principally for the development of 
flavor and appearance. The application of a high heat sears 
the surface of the meat and immediately coagulates the pro- 
teins, the hemoglobin being changed from bluish red to brown. 
Such treatment also causes changes in the surface fat, thus 
developing an additional flavor. The preliminary searing, 
usually conducted at a higher temperature than the subse- 
quent cooking, serves to retain the water and the extractives. 
The subsequent changes which occur within the roast are 
gradual, for muscle fibers are very poor conductors of heat, 
and the internal temperatures never reach those of the air 
surrounding the meat. 

As the heat gradually penetrates inward the proteins are 
coagulated at a low heat, and the hemoglobin is changed in 
color, assuming first the pink color characteristic of rare meat, 
and finally becomes brownish gray — "well done." This last 
color is common to all meats heated to a temperature above 
70° to 75° C. and is due to the complete coagulation of the hemo- 
globin. At these higher temperatures the coagulated protein, 
and consequently the piece of meat, shrinks. Careful studies of 
the physical changes occurring during roasting have empha- 
sized these points and estabhshed the conditions necessary to 
obtain the desired kind of roast — rare, medium, or "well done" 
(Sprague and Grindley). The inner temperature of the meat 
determines the degree of the roast regardless of the external 
temperature. When a thermometer placed in the middle 
of a roast registers a temperature of approximately 43° C, 
55° C, or 70° C, if the roast be removed from the oven, the 
final temperature, will be approximately 55° C, 65° C, or 
70° C, and the meat will be respectively rare, medium, or 
well done. These temperatures hold with the external tem- 
perature of the average roasting oven (175° to 195° C). At 
lower oven temperatures the temperature at which the meat 
is removed will more nearly approximate the final one desired. 

The most desirable conditions for successful "boiUng" of 
meat are long-continued heating at a temperature below the 
boiling-point, 80° to 85° C. Under such circumstances the 
connective tissue is softened and the protein coagulated with- 
out becoming hardened (toughened) characterized by the 
shrinking of the meat. Long experience in cooking has demon- 
strated the advisabihty of searing the outside of the meat or 
plunging it into boiling water and keeping it at this tem- 
perature for a few minutes before beginning the cooking at 
the lower temperature. Such a practise is held to assist in the 
formation of a more or less impervious layer by the coagu- 
lation of the surface proteins which retains the extractives 



DIGESTIBILITY OF MEAT 149 

and soluble proteins, and thereby improves the nutritive 
value and flavor. If a rich broth is desired the opposite 
method is used, beginning with cold water which is gradually 
heated. The work of Grindley and his associates, studies on 
the losses in cooking meat (see below for further discussion), 
has shown, however, that when meat is cooked at 80° to 85° C. 
there is practically no diff'erence in the quantity of nutrients 
(protein, extractives, and ash) which pass into the broth when 
the cooking is begun in hot or cold water. The length of time 
and the fat content have a much greater effect upon the losses 
than the method of cooking. 

Chemical Changes in Meat as the Result of Cooking. — The 
chemical changes which occur in meat during cooking, whether 
by roasting or boiHng, consist in an increase of insoluble 
(coagulated) protein and in the removal of water and extrac- 
tives (nitrogenous, non-nitrogenous, fat, and ash). Boiling 
causes a removal of a greater proportion of these substances 
than does roasting. Fat meats lose less water, protein, and 
mineral matter, but more fat, than do the lean cuts. Pro- 
longed cooking at higher temperatures is accompanied by 
greater losses than at lower temperatures. Under like conditions 
the larger the piece of meat the smaller are the relative losses. 
As alread}^ mentioned, when ^'boiUng'' at 80° to 85° C, the effect 
of such preliminary treatment, as placing in cold or hot water 
has Httle effect upon the quantity of material found in the 
broth. It is interesting to note that the beef used in the prepara- 
tion of beef tea or broth loses little of its nutritive value, 
although it loses much of its flavoring material. The work of 
Grindley and his associates has been verified and extended by 
that of other investigators, particularly with regard to the 
changes in the protein and extractives under various condi- 
tions. The table on page 150 taken from their results shows 
the influence of cooking upon the composition of meat. 

Digestibility of Meat. — Many conflicting statements are 
made, w^ith regard to the digestibility of meats of various 
kinds and as prepared by the various methods of cooking. 
The observations upon which the conclusions regarding the 
digestibility of meat are commonly based are of two general 
types (i) the time the food remains in the stomach and (2) 
the degree of digestion, i. e., the amount absorbed, measured by 
the quantity of nitrogenous substances excreted in the feces. 

The first method is open to the objection that it measures 
the activity of the stomach and tells nothing of the processes 
which go on in the intestines. Stomachic processes involve 
chiefly the swelling of the protein under the influence of the 
hydrochloric acid and a partial hydrolysis by the pepsin, 



150 



MEAT OR FLESH FOOD 



3 
o 
o 

o 

o 

Q 

H 

w 



-s 


O 1-^ t^ 








t^ 


lO CO ON 

(N o O 




o 


cOiO 4- 








d 


d d d 




d 1 d 


CO HI ,^ 








CO 


lOC^ CO 




1=^1 


odd 








d 


d d d 




^ 




H 












d 


00 t-i t^ 








CO 


T^OO t^ 




2 


M »0 CO 






d 


d o o 




P4 
















^* 




« -00 
o ^^ 




^ 




OnnD M 

r^Tt-NO 


^ 


hh' d ni 


g ^:: 




d 


d o d 


6 6 6 






p 














On CO On 








00 vO v£) 

^o n 


. . • 




d o^ 


S ->^ 






<0 O HH 






" 


o 












3 


O lOO 
I^COO 


^ 

J 






o 


(N O O 
T^ CO ON 


■^ CO ON 


^ 
(1) 


O) M ro 


H 
O 




tfi 


o» 


0) HH h-( 


CS M M 


111 




H 
O 


o ^ 




^ 


vO CO t^ 

cor^o 


t^ t)- ON 

CO t^ O 


H^ d ^ 


w vd 


Pi 

P3 


^ 


w d i-" 


M d 1-1 






o 
< 


' T 










00 o >o 

O vO CO 


u 


^s 




00 

o 


\0 NO CO 

o looo 


r^o lo 

O NO 00 


¥ 


M d H^ 




d On 
1 1 






H-i d d 


K^ d d 




00 ON CO 


Pi 


CO t^ 

VO 00 


O 


ON nO Onoo 


VO lO CO 

ON >-i fO 


c3 

o 


t-^h^ CO 


d CO 


;?; 


n 


« o o 


d d o 


H 


w CO M 


Q 


1 + 


O 

H 
en 








^5' 0^ 




W 




O 








2 ^ 

CU o 

ai 


ONOO (N 
(N COCO 

(M o d 


en 
W 




Ph 










rv) t^ -^ 














3 


lO lO ID 


o 










. 


:3 




g 








• 


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lO >-i n 














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3 










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u 


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00 HH O 


O NO HH 




ON t^"0 


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00 NO r^ 

ON ON ON 












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p:^ 



DIGESTIBILITY OF MEAT 151 

resulting in the reduction of the food to a semifluid mass, but 
there is Httle absorption through the gastric mucosa. More- 
over, so many variables must be taken into consideration 
accurately to measure the time required for food to leave the 
stomach that the results obtained by such experiments must, 
unless they are very striking, be considered as merely sugges- 
tive. For example, the ease of swelling and the degree of 
peptic activity are modified by the mode of preparation. Fat 
particularly tends to retard gastric digestion; there is no lipo- 
lytic activity of importance in the stomach. The composi- 
tion of the flesh Hkewise aff'ects gastric digestion, very fat meats 
being less digestible than lean meats. The presence of large 
quantities of connective tissue, particularly in partially cooked 
food, serves to hinder peptonization. Finely divided meat is 
more easily attacked by the gastric juice than large masses. 
Foods which are acid remain a shorter time in the stomach 
than do alkaHne foods. The quantity, strength, and acidity of 
the gastric juice have a very pronounced eff^ect upon the rate 
of ejection from the stomach. 

The second method of measuring digestibility — the com- 
pleteness of absorption of the ingested food — indicates only 
the extent of absorption and does not enable us to judge of 
the length of time required for its digestion. Food which is 
completely absorbed leaves little residue and is Hkely to lead 
to constipation, while that which is poorly absorbed may 
{a) be subject to extensive bacterial action in the large intes- 
tine, {h) increase the rate of peristalsis, or {c) lead to the 
accumulation of large masses of food residues in the intestines. 
In a well-selected diet, foods which are completely digested 
are accompanied by some of those which are difficult of diges- 
tion, particularly foods low in protein and rich in cellulose, 
such as vegetables and fruits. In the treatment of patholog- 
ical cases it is particularly necessary to take into considera- 
tion the degree of digestibiUty of the foods prescribed. The 
extent to which a food is absorbed depends quite as much 
upon the nature of food as does the ease of digestion. Foods 
that contain material in quantity which is not acted upon 
by the digestive enzymes are not only poorly absorbed but 
retard the digestion and absorption of other foods which are 
ordinarily completely digested and absorbed. The mode of 
preparation also influences the extent of absorption, for by its 
proper preparation connective tissue and cellulose structures 
are partially or completely hydrolyzed or disintegrated and 
thus become more readily and completely digested. 

Conventional consideration of the relative digestibilities of 
various kinds of meat is based, then, upon data which are 



152 MEAT OR FLESH FOOD 

not entirely satisfactory. Clinical observation is an aid in 
determining the digestibility of food in its most general sense, 
but here there may be influences of personal idiosyncrasies 
as the result of pathological conditions in the patient under 
observation, and this is particularly true of protein foods. 
Some individuals show distinct reactions to certain foods. 
Many cases are known, however, in which the inability to eat 
eggs, fish or milk is a psychical factor and that the ingestion 
of such foods is not attended by metabolic disturbances. 

In feeding persons whose condition necessitates prompt 
emptying of the stomach, food must be selected which will 
pass out readily, just as in certain intestinal diseases food 
must be taken in such a form that complete absorption 
occurs without extensive intestinal digestion or in which little 
residue results. These factors are discussed on p. 47. It 
seems to us that the method of the preparation and the con- 
sistency of the food are more important factors in the treat- 
ment of nutritional diseases in which a specific food substance 
is not involved, sach as a specific idiosyncrasy or disease, 
than the selection of a few from among a number of foods 
compatible with the patient. 

MEAT PREPARATIONS. 

Certain products prepared from meat, particularly from 
beef flesh, such as digested beef, beef juice, beef broth, 
beef extracts, and gelatin, contain less insoluble material 
than meat itself and are therefore held to be desirable 
not only for general use but for use in the sick-room and 
for convalescents. Such products are either readily soluble 
in water or yield fine aqueous suspensions. It is the possi- 
bility of furnishing protein or its digestion products in a fluid 
or soluble form which makes these preparations attractive for 
the special diets of therapeutics. 

The nutritive value of meat preparations as compared with 
meat depends upon the mode of preparation. They are pre- 
pared from lean meat through the action of digestive enzymes, 
with the aid of heat, or by simple water extraction. Beef 
extract and some beef broths contain only small proportions 
of nutritive protein material, whereas cold pressed beef juice, 
gelatin, and broths prepared with gelatin-3^ielding meats and 
flesh in which the proteins have been partially digested are. 
highly nutritious. The table on page 153 gives the compara- 
tive composition of such products. 

Meat Extracts. — Beef extract, the most common meat extract, 
contains the water-soluble, non-coagulable substances in meat in 



MEAT PREPARATIONS 



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154 MEAT OR FLESH FOOD 

a concentrated form. These consist essentially of non-protein, 
nitrogenous extractives such as creatine, purine bases, etc.; 
non-coagulable products of protein hydrolysis, amino-acids, 
proteoses, peptones, and gelatin, and the salts of muscle, a large 
proportion of which are salts of potassium and phosphoric 
acid; sodium chloride is sometimes added in the preparation 
of the extract. Extracts prepared from meat containing con- 
siderable quantities of connective tissue are more likely to 
contain greater quantities of gelatin. Gelatin, digested meat, 
and yeast extract are sometimes used as adulterants of meat 
extracts. Yeast extract is being used not only as an adul- 
terant but also as a substitute for meat extract. 

Meat extracts are particularly valuable as stimulants, for 
their salt contents, and as flavoring materials for otherwise 
unpalatable dishes. The extractives of meat have been shown 
to stimulate the flow of the gastric juice: in this way they tend 
to increase the digestibility of foods. Extracts to which have 
been added gelatin or finely divided protein — made more or less 
soluble by digestion or solution in acid — increase the food value 
of such preparations. The use of beef juice is, from a nutritive 
point of view, to be preferred to such preparations. 

Meat Juice. — Meat juice, particularly beef juice, is often 
prepared and used in the diet of the sick-room and for feeding 
infants. Such extracts are prepared by pressing out the water 
and soluble proteins from raw or half-broiled lean meat, pref- 
erably from finely divided meat. Preparations of this kind 
contain a certain proportion of the water soluble, coagulable 
proteins in addition to the ordinary extractives obtained by 
a method which involves heating to a temperature above the 
coagulation temperature of protein. They have, therefore, 
considerable nutritive value and may be used for the admin- 
istration of protein in a Hquid form. 

Commercial preparations of meat juice can be obtained but 
they are never as satisfactory as the freshly prepared juice 
and broths. 

Meat Broths. — Meat broths are of two kinds: (a) those that 
have been prepared by boiling beef, mutton, veal, chicken, 
etc., with water and straining off the protein material; (b) 
those prepared by extracting the juice from finely hashed meat 
with a small quantity of cold water, and expressing the water 
retained by the meat. The latter process removes a greater 
proportion of the soluble protein constituents of the meat and 
is therefore more economical. The product is, of course, more 
dilute than in the case of meat juice, above, but the greater 
proportion of protein it contains makes the two products 
comparable. The composition of the water extract varies 



MEAT PREPARATIONS 155 

of course with the quantity of water used. Such products 
contain from 2 to 5 per cent, of protein and a fraction of i 
per cent, of fat. (See table, p. 150.) Meat broths, method {a) 
are similar to meat extracts except that they have not been 
concentrated. 

Beef tea is essentially beef broth which has been prepared 
according to the second method and carried to the boiling 
point to bring about the flocculent coagulation of the dis- 
solved protein. This procedure is sometimes modified by 
slowly coagulating the proteins, extracted with cold water, 
with the finely divided meat after which the resultant liquid, 
including the flocculent coagulum and small particles of meat, is 
poured from the more solid residual meat. Beef tea contains 
approximately the same constituents as beef juice except that 
the soluble proteins are coagulated and a flavor has been 
developed by cooking. The finely divided coagulum is readily 
digestible. 

Broths are often prepared by the slow cooking of meat 
containing considerable connective tissue and the liquid 
poured oflF without straining. Such preparations are inter- 
mediate between the ordinary broths and teas; they contain 
considerable gelatin. 

Gelatin. — Gelatin is prepared from collagen-containing 
material, such as connective tissue, tendons, bones, etc., by 
hydrolysis with water (steam). A slight chemical change 
probably takes place in the formation of gelatin. The puri- 
fied product is used for food, while impure gelatin is the basis 
of glue. 

When gelatin is treated with water it swells. In hot water 
it forms a colloidal solution which sets as a jelly upon cooling. 
To such jelly-like masses fruits, fruit juices, etc., are added 
in the preparation of desserts. When heated with acid- 
containing substances gelatin is gradually hydrolyzed into 
non-gelatinizing material; this accounts for its failure to 
"jell" at times. Gelatin is also used in the manufacture of 
ice cream because of the smoothness it imparts to the finished 
product. 

Gelatin differs chemically but Httle from the protein from 
which it is derived. The amino-acids, tryptophan and tyro- 
sine, are not present, or at least they are present in very 
minute quantities; consequently gelatin cannot be used exclu- 
sively as the protein part of the diet. It has been shown, 
however, to be capable of replacing other protein to the extent 
of approximately 60 per cent. When taken with proteins rich 
in tryptophan or tyrosine it might replace an even greater 
proportion. 



CHAPTER IX. 
FISH AND SHELL FISH-POULTRY AND GAME. 

FISH AND SHELL FISH. 

Fish are an important and an economic source of protein. 
When properly prepared they are fully as palatable as meat 
and in many ways more delicate in texture. The short muscle 
fibers of fish, surrounded as they are by connective tissue 
which is readily hydrolyzed under the ordinary conditions of 
cooking, are easily broken apart, and this fact, together with 
their generally low fat content, has placed fish among the flesh 
foods which are easily digested. With the increasing facilities 
for cold storage and the realization that when properly stored 
fish show little change in their composition or in their palat- 
ability, they should become more widely used throughout the 
year than they now are. 

A large number of fish are used for food; a choice between 
them is, largely, a matter of taste and economy. When con- 
sideration must be given to their digestibility, the fat content 
becomes the controlling factor, although such fish as cod and 
carp, are held to be "coarser" than others. Variety in fish is 
not limited to those freshly caught, for processes of preserva- 
tion have been so developed that fish may be had in many 
forms: those in which they approximate fresh fish in every 
way such as the cold storage and canned fish, or those that 
have been modified in texture or flavor, by drying, salting 
(dried or moist), smoking, or preserving in oil. 

Shell fish are another source of protein. They are not, 
however, so important economically as fish. The more impor- 
tant kinds of shell fish are (a) mollusks — oysters, clams, mus- 
sels, and scallops; (b) crustaceans — lobsters, crabs, shrimps, 
and crawfish. Shell fish are used more extensively as a deli- 
cacy than as a primary source of protein. Oysters, however, 
are often used as a means of modifying the diet of invalids, 
for they are held to be easily digested. 

Fish diff'ers from meat in its chemical composition particu- 
larly in the relative proportions of fat and water. The fattest 
of the fresh fish commonly used for food contain roughly the 
same proportion of fat as the lean cuts of meat (lo to 12 per 



FISH AND SHELL FISH 



157 



cent, fat)/ while the lean types of fish contain but a fraction of 
I per cent, of fat. Associated with this lower fat content of 
fish we find a higher percentage of water than in meat. Fish 
have in general, therefore, weight for weight, a lower caloric 
value than meat. The percentage of protein is approximately 
the same in both meat and fish, but it tends to be slightly 
higher in fish. When the extractives are omitted from our 
calculation the nitrogen value of fish and meat protein is 
essentially the same. 

Our knowledge of the qualitative composition, particularly of 
the amino-acid content, of fresh fish is very limited. In gen- 
eral it appears to be quite similar to that of other kinds of 
flesh (see table, p. 134). Fish contain a relatively greater 
proportion of gelatin-yielding tissue, collagen, and a smaller 
proportion of extractives than do meats. 

The fat of fish is relatively richer in the low melting-point 
fats; it has more of the properties of oils than of "fat" as we 
ordinarily think of fat. 

Carbohydrate is present as glycogen in considerable amounts 
in certain of the fish foods — oysters, clams, scallops. It is the 
glycogen which is in part responsible for the opalescence of 
the liquor which surrounds oysters. 

The following table contains the composition of certain of 
the more common varieties of fish arranged according to their 
fat content. 

Composition of Typical Fish (Edible Portion). 









LOW IN 


FAT. 










Protein 






Fuel value 




Water, 


N X 6.25, 


Fat, 


Ash, 


per pound, 


Kind. 


per cent. 


per cent. 


per cent. 


per cent. 


Calories. 


Bass . . 


• 76.7 


20.6 


1-7 


1.2 


455 


Blue fish . 


• 78.5 


19.4 


1.2 


1-3 


410 


Cod . . 


. 82.6 


16.5 


0.4 


1.2 


325 


Flounder 


. 84.2 


14.2 


0.6 


1-3 


290 


Trout (brook) 


. 77-8 


19.2 


2.1 


I .2 


445 


Weakfish . 


• 790 


17.8 
HIGH IN 


2.4 

FAT. 


1:2 


430 


Butter fish . 


70.0 


18.0 


II .0 


I .2 


800 


Halibut . 


• 75 


4 


18.6 


5-2 


I .0 


565 


Herring 


• 72 


5 


195 


71 


1-5 


660 


Mackerel . 


• 73 


4 


18.7 


71 


1 .2 


645 


Salmon 


• 64 


6 


22.0 


12.8 


1-4 


950 


vShad . . 


• 70 


6 


18.8 


9-5 


1-3 


750 


White fish . 


• 69 


8 


22.9 


6.5 


1.6 


700 



This classification is based, in some cases, upon the analysis 
of but one or two fish, and it must be remembered that the 

' Certain cuts of meat, particularly the cheaper ones are very low in fat, i or 
2 per cent. 



158 FISH AND SHELL FISH— POULTRY AND GAME 

fat content of fish varies at the time of spawning and with 
changes in feeding conditions. Fish are found to have depos- 
ited the maximum amount of fat just before the spawning 
season and to have a minimum fat content a few weeks after- 
ward. Analyses of shad,^ a comparatively fat fish, illustrate 
this point. 

Fat wet basis, per cent. 

Shad, roe not very ripe, April 5 14-43 

Shad, roe ripe, April 15 13-93 

Shad, roe ready to spawn, April 24 5-87 

Shad, after spawning, June 19 2.95 

The same variations have been found to hold for salmon. 
The spawning season for shad is early in April and that for 
king salmon about August and September. The food supply 
also affects the composition of fish; when forced away from their 
accustomed feeding grounds by storms or natural enemies, they 
often arrive on our shores in a very lean condition. 

The following table indicates the time of year in which fish 

are in season. 

Fish and Sea Foods in Season. 



Variety. 


Season. 


Black bass. 


All year. 


Blue fish. 


April to December. 


Blue points (shell oysters). 


September to May. 


Buffalo. 


All year (except in time of low water). 


Butter fish. 


March to December. 


Cod. 


All year. 


Cape Cod (large shell oysters). 


September to May. 


Crappie. 


All year. 


Cat, channel. 


All year. 


Cat, bull head. 


All year. 


Cat, shcing (spoonbills). 


All year. 


Ciscoes (white). 


March to November. 


Carp. 


All year (except in time of low water). 


Crab meat. 


All year. 


Crab flakes. 


All year. 


Crabs, hard shell. 


All year (best season April to October) 


Crabs, soft shell. 


March to October. 


Clams, bulk. 


All year. 


Clams, shell and soft. 


All year. 


Crawfish. 


April to November. 


Eels. 


All year (scarce during winter). 


Frogs. 


February to October. 


Flounders. 


All year. 


Grass pike. 


All year. 


Hahbut. 


All year (more plentiful in summer). 


Haddock. 


All year. 


Jack salmon. 


February to November. 


Lobsters. 


All year. 


Mackerel, Spanish. 


May, June, October, November, 




December. 


Oysters. 


September to May. 


Pompano. 


May, June, October, November, 




December. 



Clark and Almy: U. S. Dept. Agr., 191 7. 



FISH AND SHELL FISH 159 

Fish and Sea Foods in Season — (Continued). 

Variety. Season. 

Perch, yellow. All year. 

Perch, white. All year. 

Roe, shad. January to September. 

Red snapper. All year (except in stormy weather). 

Salmon, California. March to December. 

Salmon, silver. March to December. 

Smelts. November to June. 

Sun fish. All year. 

Shrimp, fresh. September to December; March to July. 

Shad. January to September. 

Scallops. October to May. 

Turtle, soft shell. All year. 

Trout. April to February. 

White fish. April to December. 

The restriction of the fishing industry to certain seasons of 
the year and the difficulties of shipping have resulted in the 
extensive preservation of fish. 

Cold Storage Fish. — Fish are frozen and placed in cold 
storage in this condition (dry packed) or coated with ice. It 
has been found that fish placed in cold storage soon after they 
were caught and analyzed later, shortly after removal from the 
refrigerating plant, showed practically no change which could 
be detected chemically. Results of investigations of refrig- 
eration in general indicate, however, that food kept in cold 
storage undergoes a sHght modification which is not of a harm- 
ful nature. Studies of the palatabiHty of cold storage fish as 
compared with fresh fish have shown that where the subjects 
were entirely unbiased, cold storage and fresh fish were practi- 
cally indistinguishable. We may conclude, therefore, that 
cold storage fish which have not been kept in the market for 
more than a day or two are fully as palatable as fresh fish. 

Preserved Fish. — Canned fish are subjected to the usual 
process of cooking in the can and sterilizing. With the care 
observed at present in canning fish this form of preservation 
is most satisfactory. The flesh retains most of the charac- 
teristics of cold, cooked, fresh fish. Some -fish, particularly 
sardines, are preserved in oil or mustard sauce. In this method 
of canning, the fish are pickled in brine to toughen them 
and to add flavor, cooked with steam, dried, and finally 
packed. In the preparation of dried fish the drying is accom- 
plished by the use of salt, by pressure, or by simply drying in 
the sun or artificially. Dried cod fish are used to a consider- 
able extent and are often sold in a shredded form. Preserved 
fish are held to be less readily digested than fresh fish. 

Cooking of Fish. — Fish flesh is rich in connective tissue. 
The process of cooking hydrolyzes this with the result that 
the short muscle bundles and fibers are easily separated. Fish 



160 FISH AND SHELL FISH— POULTRY AND GAME 

is often boiled in water acidulated with vinegar or lemon 
juice, which tends to toughen the fibers and coagulate the 
protein on the outside portions and thus keep the fish intact. 
Other processes are employed to the same end, such as slow, 
quiet boihng and wrapping in cloth. 

Digestibility of Fish. — Fish are as thoroughly digested as 
other types of flesh food and meats. Estimations of its diges- 
tibility show that the protein is absorbed to the extent of 
approximately 96 per cent, and fats 97 per cent. There is 
practically no carbohydrate. Considered from the point of 
view of the ease of digestibility, fish, particularly the lean 
fish, are held to be more readily digested than the lean meats, 
while the fat fish are of the same digestibility as fat meats. 
Cooked fish is more easily masticated and consequently more 
rapidly digested than meat. Oysters are fully as digestible as 
lean fish. 

Comparative studies of the digestibility of certain types of 
fish in which the rate of nitrogen excretion and retention of 
nitrogen are taken as indices of digestibility showed that 
absorption appeared to be most rapid in the following order: 
Boiled meats — fresh cod, beef, tantog, eel, weak fish, mussel, 
salt cod, periwinkle. When the quantity of nitrogen retained 
was considered, the order was reversed. Comparison of 
freshly boiled or fried cod and salt cod showed in general that 
while the fish prepared by the former method of preparation was 
absorbed more rapidly it was not retained as well as the latter. 
Such data indicate that foods which are absorbed at a slower 
rate furnish the body with protein over a longer period of 
time, the excess at any moment is not so great and conse- 
quently the body retains a greater proportion for its use. 
From these facts it would appear that fish is fully as digestible 
as meat and, when we consider that it is poorer in fat than 
meat and that the fat of fish has a lower melting-point than 
that of meat, it would seem that fish should be, perhaps, more 
readily digested than most meats. 

POULTRY AND GAME, 

Poultry differs but little in its composition from other 
types of meat. It has in many cases a more delicate flavor 
and the fibers of the flesh are, to a certain extent, more tender. 
Its place in the diet is in the nature of a delicacy rather than 
as a staple form of food. 

The greater ease of digestibility attributed to poultry is to 
be ascribed to tradition more than to fact. Young poultr}^ 
is comparatively low in fat and for that reason undoubtedly 



POULTRY AND GAME 161 

passes more rapidly from the stomach than foods containing 
a greater proportion of fat. Poultry rich in fat, as the goose 
or duck, are, in this respect, much less digestible than chicken 
or turkey. The tenderness of the cooked flesh and the ease 
with which it is masticated, because of the short fibers, also 
contribute toward ease of digestion. Studies of the utilization 
of poultry show, however, that it is not any more completely 
absorbed in the course of normal digestion than other kinds of 
flesh, nor does it pass more readily from the stomach than lean 
meats. 

The low purine content attributed to the flesh of poultry 
as compared with other meats has been shown to be erroneous, 
for beef and mutton contain very little more purine than 
chicken. The extractive nitrogen in the white muscle has 
been shown to be higher than that of red muscle. Tables 
showing the composition of poultry are to be found on 
page 145. 



CHAPTER X. 
EGGS AND CHEESE. 

EGGS. 

The egg occupies, as does milk, an important place in the 
human dietary. It belongs primarily with protein foods — 
although by simple mechanical separation it may be divided 
into a portion containing protein egg white and into a portion 
rich in lipins, or fat, egg yolk. 

The egg is prepared for the development of the fertilized 
embryo up to the time that a fully formed chick is capable of 
breaking the shell and continuing its growth with food obtained 
by its own effort. The nutritive material for this restricted 
growth, which includes the formation of the skeletal, muscu- 
lar, and organic systems as well as the maintenance of the 
growing tissues, is contained in the yolk, white, and shell. 
Its constituents are therefore both highly nutritious and 
concentrated; its dietary usefulness is self-evident. 

Eggs are important not only as a simple food, but also as 
an essential constituent of certain prepared foods — cakes, cus- 
tards, and confectionery. 

Since eggs^ contain quantities of iron and calcium and are 
also easily digested, they are a desirable supplementary food 
for young children, and an acceptable food for convalescents 
and invaUds. 

The egg consists grossly of three parts — shell, white and 
yolk. The relative proportion of these in the egg varies some- 
what with different breeds of hens; in general, they are shell, 
II per cent.; yolk, 32 per cent.; and white, 57 per cent, of the 
total weight of the egg. These parts may be mechanically 
separated with relative ease. Only the white and \^olk are 
used for food. The average weight of the edible portion of an 
egg is 50 grams. 

The following table gives the composition of the various 
parts of the hen's egg. 

^ In this discussion wc restrict our remarks to the egg of the hen, unless other- 
wise stated. The egg of the duck, goose, turkey, guinea fowl, many wild fowl, 
and certain amphibians, as turtle and alligator, are used for food, but seldom 
to the extent to which the hen's egg is utilized. Their properties are very similar. 



EGGS 163 

Comparative Composition of the Edible Portions of the Egg.^ 

Edible 
portion 

(whole egg), White, Yolk, 

Constituents. per cent. per cent. per cent. 

Water 73 . 7 86 . 2 ' 49 . 5 

Protein 13.4 12.3 15.7 

Fat 10.5 0.2 33.3 

Ash i.o 0.6 I.I 

Potassium, K2O 0.165 o.ig 0.13 

Sodium, N a 2O 0.2 0.21 o.i 

Calcium, CaO 0.093 0.015 0.2 

Magnesium, MgO 0.015 0.015 0.02 

Phosphorus, PcOs 0.37 0.03 i.o 

Chlorine, CI o.io 0.15 o.i 

Sulphur, S 0.19 0.20 0.16 

Iron, Fe 0.003 o.oodi 0.0085 



50.0 


330 


17.0 


1.8 


1 .2 


0.6 


74.0 


17.0 


60.0 


68.0 


194.0 


28.0 



Weight of average egg, grams 
Weight of average egg, ounces 
Fuel value, average egg. Calories 
Weight, 1 00- Calorie portion, grams 

^gg White. — Egg white, when raw, is a viscous, semiliquid 
mass having a sHghtly greenish tinge and practically no flavor; 
the reaction of the egg, when fresh, is very sHghtly alkaHne. 
It consists almost entirely of protein, water, and salts; though 
a small amount of carbohydrate is present. Water predomi- 
nates, as it does in all animal tissue or products. There are 
several proteins in egg "albumen," ovalbumin, conalbumin, 
ovoglobuHn, ovomucin, and ovomucoid. The albumins which 
predominate and comprise approximately 90 per cent, of the 
total protein are similar in composition. They diflPer in their 
ability to crystallize from a solution of ammonium sulphate. 
OvoglobuHn exists to the extent of about 6.5 per cent, of the 
total protein; it is probably not an individual protein but a 
compound. The glycoproteins, mucin and ovomucoid, are 
present in small amounts. Egg white is practically free from 
fat. The inorganic constituents of the egg white are chiefly 
phosphorus and calcium. The sulphur in albumen is the source 
of the hydrogen sulphide in the spoiled egg. 

Egg Yolk. — Egg yolk is particularly rich in lipins (fats and 
lipoids). The relatively high caloric value of egg yolk, ap- 
proximately seven times that of egg white, is to be ascribed 
to its lipin content. The lipin constitutes approximately 20 
per cent, of the solid constituents of the yolk. The glycerides 
of palmitic acid, 38 per cent.; stearic acid, 15 per cent.; and 
oleic acid, 40 per cent., are the principal fats present. Of the 
lipoids, lecithin is present to the extent of approximately ii 
per cent, and cholesterol 1.5 per cent. The composition of 

• Compiled from Sherman: Food Products, 19 14. 



164 EGGS AND CHEESE 

egg fat varies with the diet of the hen; certain character- 
istics of ingested food are often transferred to the egg and 
modify the color, odor, or taste. The color of eggs particu- 
larly varies with the nature of the ingested food; green vege- 
tables, etc., tend to produce a darker colored yolk than do other 
foods. The feeding of fish affects the taste of eggs and it has 
been shown that benzoic acid when fed to hens appears in the 
egg. The lipins exist in egg yolk as a fine emulsion. The 
low melting-point of egg fat and the fact that the fat is highly 
emulsified make the yolk easy to digest and therefore valuable 
as a food for the sick. 

Of the proteins in egg yolk, the phosphoprotein, vitellin, is 
the most important. It has been shown that vitellin exists 
in the yolk as a lecithin-nucleovitellin compound or mixture 
containing from 15 to 30 per cent, of lecithin combined with a 
lecithin-free substance which has been designated nucleovitellin. 
Purine bases are practically absent from the egg; they are 
contained only in the nucleus of the yolk. 

Eggs and particularly egg yolk are a good source of phos- 
phorus, iron, and calcium. The phosphorus occurs almost 
entirely as organic phosphorus — lecithin and vitellin; certain 
other phosphorus-containing lipoids are also present. Iron is 
in organic combination. It exists in a complex molecule which 
contains in addition to carbon, hydrogen, oxygen, and nitro- 
gen; iron, 0.455 P^'^ cent.; calcium, 0.352 per cent.; and mag- 
nesium, 0.126 per cent. This compound has been called hema- 
togen because it is supposed to be the precursor of hemo- 
globin. The composition of the compound has not been found 
to be the same under different methods of preparation; it may 
be a mixture of substances. The ash of the egg is predomi- 
nantly acidic. 

The table on page 163 shows the quantity of the more impor- 
tant mineral constituents of egg in the percentage of the total ash. 

Cooking of Eggs. — Eggs are prepared for the table by boiling 
in the shell, dropping into hot water (poaching), or frying over a 
hot plate. The degree of coagulation of both white and yolk 
in boiled eggs is a matter of great personal taste and habit. 
There are three average degrees of hardness to which an egg 
may be boiled — soft-cooked, in which the white resembles a 
soft, thick curd and the yolk is fluid; medium-cooked, in which 
the white is firmer though still soft and tender, and the yolk 
is thickened, and hard-cooked, in which both the white and 
yolk are completely coagulated and quite firm. A certain 
flavor is developed upon cooking which is best in the medium- 
cooked egg. Of the three methods of boiling eggs: cooking in 
continuousl}^ boiling water for a certain length ot time; or 
placing in cold water and bringing it to a boil; or placing in 



EGGS 165 

boiling water which is no longer heated, the last, which involves 
cooking below the boiling-point, is the best, both for the con- 
sistency of the white and yolk and, as we shall see, for its 
digestibility. With this procedure the texture of the egg can 
be readily controlled. It has been found that an egg taken 
from the ice-chest, when placed in one pint of water, in a 
quart stew pan, which has been brought to a boil over a gas 
flame and allowed to remain six minutes was soft-cooked; the 
temperature of the water dropped from (212° F.) the temper- 
ature of boiling water to 185° F. upon the addition of the egg, 
and then steadily to 170° F. If the egg remained in the water 
eight minutes it was medium-cooked and the temperature of 
the water had fallen to 162° to 164° F. These data relate to one 
egg. For a greater number of eggs the amount of water must 
be increased proportionately or the time lengthened. A little 
experience will fix the time required for conditions which differ 
from those outlined above. 

Poached eggs are similar in consistenc}^ to boiled eggs. In 
this case the yolk and white are coagulated in the water 
instead of in the shell and there is undoubtedly a slight but 
negHgible loss of mineral matter. 

Fried eggs are cooked at a relatively high temperature with 
the use of fat of some kind, factors which increase the flavor of 
the eggs but which tend to decrease the ease with which they 
are digested. 

The function of the egg in cakes, in addition to its fuel 
value, is to ensure Hghtness. Egg protein plays the most 
important role in the process. As the result of whipping or 
beating fine bubbles of air are incorporated into the viscous 
egg. When this beaten mass is mixed with the other ingred- 
ients and cooked, the expansion of these air bubbles and other 
gas bubbles formed by the leavening agents and the coagula- 
tion of the surrounding protein produce the comb-like structure 
indicative of "lightness" in such foods. 

Digestibility of Eggs. — From a quantitative point of view 
egg protein is as digestible as meat or milk protein; the protein 
and lipin of eggs show a high degree of absorbability. Egg 
white, raw or soft-boiled, when fed alone tends to leave the 
stomach more rapidly than other protein material. Raw egg 
white has been observed to begin to pass from the stomach, 
without becoming acidified, almost immediately after inges- 
tion. Later the remaining food becomes acid and passes out 
more slowly. It is interesting in this connection to know that 
raw egg white does not excite the flow of the gastric juice any 
more than water does. 

Cooked egg white passes from the stomach at a rate which 
appears to depend more upon its consistency than on the 



166 EGGS AND CHEESE 

extent to which it is cooked. Particles of *' hard-boiled" eggs 
leave at a slower rate than soft-boiled eggs, although thorough 
mastication tends to increase the rate of evacuation. 

In a comparative study of the digestibihty of eggs cooked 
in various ways it was found that eggs when eaten raw, or 
after being soft or hard boiled had completely left the stomach 
at the end of periods as follows: 

Raw I hour, lo minutes 

Soft-boiled i^ hours . 

Hard-boiled 2^ hours 

The amount of gastric juice poured out in each case was: 

Raw 399 c.c. 

Soft-boiled 372 c.c. 

Hard-boiled 481 c.c. 

While raw egg leaves the stomach much more rapidly than 
soft-boiled egg it has been repeatedly shown that it is not so 
rapidly or completely digested in a given time in the stomach 
or upper part of the small intestine as soft-boiled eggs. Large 
quantities of raw egg white may cause diarrhea. The indiges- 
tibility of raw egg white is related to its chemical constitution, 
or perhaps to the presence of antitrypsin, than to its physical 
texture. When considered on the basis of the rate of eUmi- 
nation of nitrogen, raw and hard-boiled eggs are not as rap- 
idly absorbed as other protein substances, e. g., meat, gelatin, 
or casein. This has been ascribed for raw egg to the short 
time which it stays in the stomach and to the possibility that 
its digestion is difficult in the intestine. In the case of coagu- 
lated egg white the slowness of absorption has been ascribed 
to the compactness and impermeable character of the 
particles. 

Preserved Eggs. — The fact that a greater number of eggs are 
produced at certain seasons of the year than at others has led to 
the practice of storing them in the refrigerator and otherwise pre- 
serving them in salt, water-glass, etc., and by desiccation and 
freezing. Eggs kept in cold storage change slightly, as do all 
cold storage products, according to the length of time they are 
kept there. They gradually develop a taste and odor different 
from that of a fresh egg. Water passes from the white to the 
yolk with a resultant increase in the size of the }'olk and, it 
the increase be sufficiently great, the yolk membrane is weak- 
ened or ruptured. Moisture is lost through evaporation. 
There is an alteration in the properties of the white, upon 
which its value for cooking depends, perhaps as the result of 
autolysis. These changes do not develop sufficiently in a 
period of a month or six weeks to alter the characteristics ot 



CHEESE 167 

the egg from those of a moderately fresh egg. Eggs kept for 
a greater time show proportionately greater change. 

One of the most important objections to cold-storage eggs 
is that they are usually sold for fresh eggs. Good cold-storage 
eggs are very useful in cooking and are often nearly as pal- 
atable as fresh eggs. When eggs are sold as *' cold-storage" eggs 
they are an important economic factor in the diet. Present 
methods of rapid drying yield dried-egg preparations which 
are satisfactory for cooking and general use where the intrin- 
sic character of fresh eggs is not an essential consideration. 
The objection to dried eggs has been that they are sometimes 
prepared from decayed eggs. When it is known that they are 
properly prepared from fresh eggs they are satisfactory for use 
as indicated above. 

Egg Substitutes. — Preparations which consist of some form 
of protein and a small amount of coloring matter are placed 
on the market as substitutes for eggs. Custard powders are 
offered which are essentially starch and seldom contain egg and 
often no protein. 

CHEESE. 

Cheese is a preparation made from milk or cream by coagu- 
lating the caseinogen with rennin. The casein thus formed is 
subjected to the action of bacteria, moulds or enzymes which 
"ripen" the cheese, producing changes in the flavor, consistency, 
and composition of the product. Cheese, without any desig- 
nation to indicate a modification, contains approximately one- 
third each of water, protein, and fat; that is, roughly, 50 per 
cent, of the soUd matter is butter fat. The designations, 
"cream," "full cream," "whole milk," and "milk," although 
used more or less interchangeably in this country, indicate 
that the cheese is made from whole milk or sometimes from 
milk and cream. Some cheeses are made from skimmed milk 
"filled" with fat other than butter fat, as lard, cotton-seed 
oil, etc. Goat's milk is sometimes used in preparing cheese. 
The greater proportion of American cheeses are, however, 
made from cow's milk. Cheese, from the mode of prepara- 
tion, is then a combination of the greater portion of the 
protein, caseinogen, and the fat of milk. It contains a large 
proportion of calcium and phosphorus combined with the 
casein and a smaller proportion of the other salts and lactose 
present in milk; salt (sodium chloride) is added in the process 
of manufacture of cheese. 

There are two types of cheese: the hard cheeses of the 
Cheddar, "American cheese," type (Cheddar, Edam, Emmen- 
tal (Swiss), Parmesan, and Roquefort) and the soft cheeses 
(brie, camembert, gorganzola, Limberg, Neufchatel, and Stil- 



168 EGGS AND CHEESE 

ton). These cheeses vary in their consistency and flavor 
according to the manner of preparation. Cottage cheese is a 
term appHed to ^'unripened" casein and is usually prepared at 
home from sour milk, although it can be obtained from dairies 
in many cases. 

In the process of ripening there is an increase in the soluble 
protein (proteose, peptone and amino-acids), indicating a partial 
digestion of the protein; while the fat is not so completely emul- 
sified as in milk, it does not appear to undergo any extensive 
modification. 

The composition of cheeses of various fat content in com- 
parison with other milk products is given on page 123. 

Digestibility of Cheese. — Cheese is as completely utilized as 
other protein foods. Its digestibility has been shown to be 
approximately equal to that of meat, eggs, etc. The general 
opinion that cheese is indigestible is due to the fact that the 
casein of cheese is associated roughly with an equal quantity 
of fat which tends to prolong its stay in the stomach, and 
that the volatile fatty acids and certain of the protein 
cleavage products formed during the ripening process may be 
irritating to the stomach. Careful chewing of cheese when 
eaten alone should increase the *'ease" of digestibility, for 
the finely divided particles will tend to leave the stomach 
more rapidly than the larger pieces of cheese. 

Cheese should be served with starchy foods and vegetables, 
for it is rich in protein and fat and very poor in carbohydrate. 
When so served it is a most desirable article of diet. Since 
cheese is comparatively cheap it may be used to advantage 
in the variation of the protein part of the diet in place of 
meat and fish. 

Casein Preparations. — A number of specially prepared foods 
can be obtained whose base is chiefly casein. These may be 
the dried calcium caseinate obtained from milk with additional 
food-stuffs, or the water soluble salt, or salts of the stronger 
alkalis, sodium or potassium; glycerophosphates are some- 
times added. The nutritive value of these preparations is 
approximately that of casein. The therapeutic value which 
is claimed for many of them is probably overestimated for 
the same quantity of casein taken as milk or freshly coagu- 
lated skimmed milk or even as soft cheese (cottage cheese) 
undoubtedly possess all the advantages of these prepara- 
tions and in addition the constituents of milk, fat, salts, 
lactose, and accessory substances, which have been shown to 
be in many ways desirable. The prepared products are desir- 
able in diets which are too low in fat and sugar, or where the 
protein content is to be increased without an increase in bulk 
P^or further discussion, see section on Clinical Dietetics. 



CHAPTER XI. 
PROTEIN-RICH VEGETABLE FOODS. 

LEGUMES. 

Certain vegetable foods, particularly the legumes, are rich 
in protein, and are at the same time comparatively poor in 
carbohydrate; others, such as nuts, contain considerable quan- 
tities of fat. It is desirable to classify these foods as protein- 
rich foods. The grains, wheat, barley, oats, corn, etc., are 
likewise comparatively rich in protein (lo to 12 per cent.). 
Carbohydrate predominates, however, and this fact together 
with the place of these foods in the average diet, serves to 
differentiate them into the class of carbohydrate foods. The 
legumes and nuts are preserved in a semidried state in which 
they may be kept almost indefinitely. Their low water con- 
tent and comparatively high protein content make them a 
valuable source of protein when transportation is a problem, 
as in hunting and campaigning in war. These foods are rela- 
tively cheap and are therefore a valuable source of protein 
in diets of low cost. 

The vegetable and animal proteins are in many ways simi- 
lar in both their physical and chemical properties. In general, 
vegetable proteins yield more glutamic acid and in some cases 
proline, arginine and ammonia than do the animal proteins. 
Many of them are deficient in one or more essential amino- 
acids but they do not differ in this respect from certain animal 
proteins (gelatin). In seeds, the form of vegetable protein 
food with which we are particularly concerned, most of the 
protein is found in the endosperm, as reserve protein surround- 
ing the embryo. Proteins of the globulin, glutelin and pro- 
lamine type predominate in the endosperm. Legumes are 
particularly rich in globuHns, the legumins. These proteins 
form salts with calcium which are insoluble in water. It is 
the formation of these compounds which accounts for the diffi- 
culty encountered in cooking peas and beans in hard water — • 
the failure to soften. The use of water poor in calcium, as 
distilled water, or water softened with sodium carbonate, 
overcomes the difficulty. In addition to these proteins the 
embryo contains others which are more varied in character 
and apparently similar to the physiologically active animal 



170 



PROTEIN-RICH VEGETABLE FOODS 



proteins, as albumin, nucleoprotein. The following proteins 
have been found by Osborne to be present in wheat: 





Spring wheat, 


Winter wheat 




per cent. 


per cent. 


Glutenin 


4.68 


417 


Gliadin 


396 


3 90 


Globulin 


0.62 


0.63 


Albumin 


0.39 


0.36 


Proteose 


0.21 


0.43 



It is from the nucleoprotein in the embryo that the 
greater proportion of the small amount of purine bases con- 
tained in the legumes and nuts is obtained. The following 
table gives the quantity of purine bases in certain of these foods. 



Purine Bases in Vegetable Foods. 



Practically absent. 
White bread 
Rice 
Tapioca 
Cabbage 
Lettuce 
Cauliflower 



Present percentage of purine base 
nitrogen. 

Oatmeal 0.021 

Pea meal .... 0.016 

Beans 0.025 

Lentils 0.025 

Potatoes 0.0008 

Onions 0.0031 

Asparagus (cooked) . 0.0086 



The difference in composition between fresh and dried 
legumes is to be ascribed to variations in the water content. 
Fresh shelled beans and peas contain a large proportion of 
water. The removal of water in drying is accompanied by a 
relative increase in the nutritive constituents. The accom- 
panying table gives the composition of typical fresh and dried 
legumes rich in protein. 

Comparative Composition of Protein-rich Vegetable Food with 
Other Foods (Edible Portion). 









Protein 




Carbo- 




100-Calorie 




Water, 


(Nx6.25), 


Fat, 


hydrate, 


Calories 


portion. 




per cent. 


per cent. 


per cent. 


per cent. 


per pound. 


gm. 


Legumes, dried 


12.6 


22.5 


1.8 


59 6 


1567 


29 


Legumes, fresh 


68.5 


71 


0.7 


22.0 


557 


82 


Nuts . . 


2.4 


18.4 


64.4 


13.0 


3182 


14 


Cereals . 




12.0 


II. 4 


I.O 


75-1 


1610 


28 


Lean meat 




70.0 


21.3 


7-9 




652 


64 


Dried beef 




54-3 


30.0 


6.5 


0.4 


840 


56 


Fish, lean 




75-4 


18.6 


5-2 




550 


83 


Milk . . 




87.1 


3-3 


4.0 


50 


314 


145 


Cheese . 




35 


27.7 


36.8 


4.1 


2080 


22 


Eggs . . 




73-7 


13 4 


10.5 




672 


68 



In the preparation of the dry legumes for consumption a 
considerable amount of the water lost in drying is restored, 
thus yielding a food of considerable bulk in proportion to its 
protein content. This comparatively large bulk of legumes 



SOY BEAN 



171 



which must be ingested to furnish the requisite amount of 
protein constitutes one of the chief objections to a vegetarian 
diet. 

The fat content of legumes is low. There are, however, one 
or two exceptions; soy beans and peanuts are comparatively 
rich in fat. Accompanying the high fat content of these 
legumes we note a smaller proportion of carbohydrate. The 
legumes have a relatively high ash content. Potassium, 
phosphate and iron are abundant: the proportions of these 
and of other ash constituents will be found on page 207. 

Soy Bean. — The soy bean is particularly rich in protein, con- 
tains a high percentage of fat, and is poor in carbohydrate. The 
sugar content is relatively high. In China and Japan the soy 
bean is prepared in various ways in the form of cheeses and 
sauces in which the beans are cooked, mixed with various 
grains and subjected to the action of bacteria — shoyu, natto, 
miso — or precipitated and, after removing most of the water, 
pressed into cakes or tablets (tofu). Because of its low starch 
and high fat and protein content the soy bean has assumed 
an important place in the diet of the diabetic. The carbo- 
hydrate is chiefly in the form of sucrose, hemicellulose, and 
cellulose. The following data give the result of the analysis 
of a soy bean: 

Soy Bean (Hollybrook).^ 

Water .... 

Ash 

Protein (N x 6.25) . 
Ether extract 
Nitrogen-free extract 

Constituents in Nitrogen-free -Extract. 

Galactan . 

Pentosan . 

Raffinose . 

Starch 

Cellulose . 

Undetermined hemicellu 

Dextrin 

Sucrose .... 

Invert sugar ... 

Organic acids (as citric) 

Waxes, color principles, tannins, etc. (by difference) 



Per cent. 


12.67 


4 
36 


64 
69 


14 
31 


92 

08 


4.86 


4 


94 


I 


13 





50 


3 


29 





04 


3 


14 


3 


31 





07 


I 
8 


44 
60 



The quantity of sucrose and starch present in the soy bean 
varies chiefly with the manner in which the bean is allowed 
to ripen or the time at which it is gathered. Those which are 
not permitted to ripen thoroughly or which are allowed to 



Street and Bailey: Jour. Ind. and Eng. Chem., 1915, vii, 853. 



172 PROTEIN-RICH VEGETABLE FOODS 

ripen after the vine is cut are more likely to contain starch 
than others. Beans which are permitted to become thor- 
oughly ripe are practically free from starch. 

Peanut. — The peanut, Hke the soy bean, is rich in protein and 
fat and poor in carbohydrate, and is therefore a most satis- 
factory diabetic food. Peanut butter, prepared from peanuts 
by grinding, is even richer in protein and fat than the untreated 
peanut itself. 

Preparation of Legumes. — Legumes are prepared for the 
table by boiling in water, baking, or roasting. Partially 
broken or ground into flour the legumes are used in soups: 
split-pea soup, for example, is a most palatable and nutritious 
dish. The eff'ect of cooking legumes is to soften the cellu- 
lose structures, hydrate the starch, coagulate the protein, and 
develop flavor. Fresh peas and beans are cooked without 
other preparation than the removal of their pods. Since the 
cellulose is still soft, the time required for cooking is com- 
paratively short. Dried legumes, however, must be soaked 
in water, swollen, before they are cooked, and, because of the 
hardened condition of the cellulose must be heated for a long 
time to ensure the complete softening of the cellulose and the 
rupture of the starch granules. Soaking of dried legumes in 
some cases permits the removal of the indigestible skin sur- 
rounding the bean or pea. Certain bitter constituents are 
also removed in the soaking process. To prevent the formation 
of insoluble calcium-protein compounds, which occurs when 
hard water is used, legumes should be soaked and cooked in 
soft or distilled water. 

The digestibility of dried legumes, even after cooking, is 
slightly lower than that of the flesh foods. Digestion experi- 
ments show that while the carbohydrate and fat — usually 
added to them in preparation — are readily digested and 
absorbed, the protein is not completely digested; the degree 
of digestion is estimated at approximately 80 per cent, for 
legumes, as compared with 95 per cent, for meat. That the 
low digestibility of legumes is due largely to the cellulose 
structures which prevent digestion and absorption is shown 
by the greater digestibility of the cooked food and the fact 
that the protein of finely ground legumes is practically as 
well absorbed as meat protein. 

The general contention that legumes are indigestible has 
been ascribed to the consciousness of the digestive processes 
experienced following the ingestion of these foods. Such indi- 
cations are heightened in some people by the flatulence which 
often occurs during digestion. The economic importance and 
food value of legumes have been discussed on page 116. 



NUTS 



173 



Nuts. — Nuts are seldom used as a staple article of diet. They 
might well be so used, for they are particularly rich in both 
protein and fat. Studies of the digestibility of nuts are few. 
It has been shown that in a fruit-and-nut diet the food 
constituents are practically as digestible as those of a mixed 
diet. 

Digestibility of Fruits and Nuts. 



Fruits and nuts. 
• 90 



Protein 

Fat 85 

Starch and sugar 96 

Crude fiber 54 

Ash 68 

Energy 86 



Mixed diet. 

94 
92 
96 
49 

88 



The protein is, however, slightly less digestible. Nuts are 
generally held to be, physically, indigestible because they often 
produce a feeHng of discomfort upon ingestion. This is no 
doubt largely due to excessive ingestion and poor masti- 
cation. The high fat content of nuts will tend to retard the 
passage of food from the stomach and this delay may also be 
a contributing factor to the conception of indigestibility. 
When eaten properly, nuts are a digestible and valuable food. 
The accompanying table gives the composition of the more 
important nuts. 

Composition of Typical Fruits and Nuts (Edible Portion). 







Protein 




Carbo- 




100-Calorie 




Water, 


(N X6.25), 


Fat, 


hydrate, 


Calories 


portion, 




per cent. 


per cent. 


per cent. 


per cent. 


per pound. 


gm. 


Almonds 


4.8 


21.0 


54-9 


17.3 


2940 


15 


Brazil nuts . 


5-3 


17.0 


66.8 


7.0 


3162 


15 


Chestnuts, fresh 


450 


6.2 


5-4 


42.1 


1097 


43 


Chestnuts, dried 


5 9 


10.7 


7.0 


74.2 


1828 


25 


Cocoanut 


14. 1 


5-7 


50.6 


27.9 


2675 


17 


Hickory nuts 


3-7 


154 


67.4 


II. 4 


3238 


14 


Peanuts^ . . . 


9.2 


25.8 


38.6 


24.4 


2490 


18 


Pecans 


2.7 


9.6 


70.5 


153 


3330 


14 


Walnuts, California 


L 2.5 


18.4 


64.4 


13.0 


3200 


14 



Legume. 



CHAPTER XII. 
CARBOHYDRATE-RICH FOODS. 

Carbohydrates are one of the two important classes of 
energy-yielding food-stuffs. Studies of the respiratory quo- 
tient of men have demonstrated repeatedly that when the 
body has a choice between fat and carbohydrate to be used 
in the production of energy or work, particularly when there is 
a sudden call upon the body resources, carbohydrate (glucose) 
is the first to be utilized and, when this is gone, the fats. When 
carbohydrates are entirely lacking in the diet, or have been 
withdrawn from the body, marked disturbances in metabolism 
occur, particularly in fat metabolism. The chief disturb- 
ance is evidenced by an incomplete oxidation of the fats, 
resulting in a condition known as acidosis. The evidence is, 
for man at least, that carbohydrate is essential to the normal 
continuance of body functions, and that when this is not 
supplied in the food, it must be formed from protein. 

In considering carbohydrate foods we will include those 
foods in which carbohydrates predominate. Such a classifica- 
tion includes some foods, such as cereals, which are com- 
paratively rich in protein; their chief place in the diet is, 
however, as a source of carbohydrate. The potato and banana 
will also be considered here, for even though they might be 
classed with the succulent vegetables and fruits, they serve 
as valuable sources of carbohydrate. 

For dietetic purposes, carbohydrates are quite often classified 
as sugars, starches, and cellulose. Such a division is sufficient 
for most practical purposes; it does not, however, serve for 
differentiation on the basis of their chemical composition. The 
following classification is based upon the relative complexity 
of the carbohydrate molecule: 
I. Monosaccharides. 

1. Pentoses, C5H10O5: (a) Arabinose; (b) xylose; (c) 

rhamnose (methyl-pen tose), C6H12O5. 

2. Hexoses, CgHi^Og: (a) Glucose; (b) fructose; {c) 

galactose. 
II. Disaccharides, C12H22O11: (i) Maltose; (2) lactose; (3) 
isomaltose; (4) sucrose. 
III. Trisaccharides, Ci8H320i6: (i) Raffinose. 



SUGARS 175 

IV. Polysaccharides (C6Hio05)x: (i) Gum and vegetable 
mucilage group: (a) Dextrin; (b) vegetable gums. 
(2) Starch group: (a) Starch; (b) inulin; (c) glyco- 
gen; (d) lichnin. (3) Hemicellulose group: (a) Cellu- 
lose; (b) hemicellulose. (i) Pentosans, gum arabic; 
(2) Hexosans, galactans, agar agar. 
The carbohydrates of particular dietetic importance are 
the monosaccharides, having six carbon atoms, the hexoses, 
or compounds whose molecules are multiples of these, such as 
the starches. 

SUGARS. 

The term sugar is, by convention, applied to the disaccha- 
ride sucrose obtained chiefly from the juice of the sugar-cane, 
sugar-beet, and maple tree. Other simple mono- and disac- 
charides, such as glucose (dextrose or grape-sugar), fructrose 
(levulose or fruit-sugar), lactose (milk-sugar), maltose (barley- 
or malt-sugar) are also classed among the sugars. The sweet- 
ness of various fruits and vegetables is due either to sugar, its 
products of hydrolysis or a combination of these. Unless it is 
specifically defined or inferred, the term sugar applies, in the 
following discussion, only to sucrose. 

Sucrose. — Sugar (cane-sugar, beet-sugar, sucrose) is widely 
distributed in the vegetable kingdom. Upon digestion or 
hydrolysis it yields one molecule each of fructose and glucose. 
The combined effect of these two sugars upon polarized light 
is to rotate it in the opposite direction from that produced by 
the solution of sucrose from which it was obtained. For this 
reason the hydrolyzed mixture is called invert sugar. 

The sugar of commerce is obtained almost exclusively from 
the sugar-cane and the sugar-beet. There is often a discrimi- 
nation between the two. Cane-sugar is supposed to be purer 
and more satisfactory for certain culinary processes, such as 
canning and jelly making. As far as the sucrose is concerned 
there is no diflPerence, and between the highest commercial 
grade of each there is no distinction. The cheaper grades of 
beet-sugar may have a bitter taste or an odor suggestive of 
glue. 

In the manufacture of sugar the juice is expressed (cane- 
sugar) or extracted (beet-sugar), treated with lime to clarify 
it, filtered, and evaporated in vacuo. Upon standing the first 
crop of crystals separate from the concentrated liquid. The 
mother liquid or first molasses is removed by draining or 
by centrifugal force. This liquid is then diluted and a second 
lot of sugar and molasses obtained. This process is often 
carried out for a third time. The yellowish or brown sugar 



176 CARBOHYDRATE-RICH FOODS 

obtained by crystallization from the molasses is usually 
refined by redissolving, clarifying, decolorizing, and finally 
recrystallizing. Crude cane-sugar is often sold as brown sugar. 
Crude beet-sugar, however, has a rather unpleasant flavor, 
and is not usable. 

In addition to the final product, sugar, the molasses or 
mother Kquid remaining after the first crystallization from 
the juice of the sugar-cane and the mother liquor from the 
crystallization of the refined sugar are used as food. The 
latter is often mixed with glucose, or corn syrup, and sold as 
*'corn syrup with cane flavor." 

Glucose. — Glucose (dextrose or grape-sugar) is found, most 
widely distributed in the plant and animal kingdom. It 
occurs in the free state and in combination with other sugars. 
It is the end-product of the digestion of starch, glycogen and 
maltose, and one of the products of the hydrolysis of sucrose 
and lactose. In the body it is the form of carbohydrate 
present in the blood. Glucose is assuming an important 
place in the manufacture of syrups and confections and is 
often used by manufacturers in place of cane-sugar. It is 
prepared from starch by the action of acids which hydrolyze 
it, yielding a product known as "commercial glucose," or 
"corn syrup," a viscid liquid mixture of glucose, maltose, 
and dextrin. The complete hydrolysis of starch yields prac- 
tically pure glucose which, upon recrystallization, is sold as 
starch-sugar or grape-sugar. 

Glucose is often used in the preparation of preserved fruit 
products and as such it is considered an adulteration. Many 
artificial jams or fruit butters are prepared from apple pulp 
which, when flavored and colored^ are sold as jams of diff'erent 
kinds. The present pure food laws require such preparations 
to be labelled as artificial. As far as their food value is con- 
cerned they are as satisfactory as the true products. 

Lactose. — Lactose, the sugar in milk, yields galactose and 
glucose upon hydrolysis. It is not as sweet as cane-sugar and 
is therefore often a valuable food in cases where it is desired 
to raise the caloric value of the diet. It is a concentrated 
form of carbohydrate, and is readily absorbed. Further, it 
has been shown that fermentation in the stomach does not 
take place as readily with lactose as with sugar. Coleman has 
used lactose successfully to increase the caloric value of the 
diet of typhoid fever patients. 

Maltose. — Maltose, one of the digestive products of starch, 
is composed of two molecules of glucose. It occurs in the diet 
usually as the result of special preparation, as in the prepara- 
tion of malt or the preliminary digestion of food. 



SUGARS 



177 



Maple-sugar. — Maple-sugar is obtained from the sap of the 
sugar-maple. The sap is evaporated in open kettles and the 
sugar allowed to crystallize into a soUd mass. Maple-sugar is 
seldom refined; it contains in addition to the sugar certain 
ethereal substances and organic acids which give to it the 
characteristic flavor. When the concentrating process is not 
carried far enough for the sugar to crystallize, maple-syrup is 
obtained; the greater part of the sugar from the maple tree is 
sold in this form. 

Invert Sugar. — Invert sugar, a mixture of equal parts of 
glucose and fructose, is seldom sold as such. It is found in 
ripe fruits and vegetables, molasses from cane-sugar, and often 
in jellies and confections as the result of hydrolysis. 

Fructose. — Fructose (levulose or fruit-sugar) is found in fruit 
associated with glucose, as invert sugar (see above). Inuhn, 
the starch-like substance in the roots of the dandelion, chicory 
and the tubers, and of artichokes yields fructose upon hydrolysis. 

Candy, Jams and Jellies. — ^The sugars are important constit- 
uents of confectionery, preserves and jams. Candy is 
essentially cane-sugar or glucose to which certain flavoring 
and coloring substances and sometimes a filling material has 
been added. In the commercial preparation of many candies 
sugar is partially hydrolyzed to invert sugar, which gives them a 
greater smoothness. 

Preserves, jams, and jeUies are essentially fruit pulp or juice to 
which sugar has been added and the whole boiled to the proper 
consistency. Their food value is largely due to the sugar. 
The gelatinizing constituent of jellies is the pectin of the fruit 
(p. 210). When this is deficient it is often obtained from other 
fruits, giving the mixed jelhes. Acid is also necessary in the 



Composition of 


Jams and Jellies and 


THE TUICES FROM 


WHICH They 








t; WERE 


Prepared. 














r 






Sugars. 












i 




-fa" 


i 
3 


II 




1 


G 


^ 




S 

u 


1 





3 




u 

S. 





+j 

IS 







II 




03 r 




1 


p. 

4 


IS. 


3fe 


'0 

:3 


1 


ii 






cs 


< 


< 


^ 


Ph 








< 


Grape: 


















Juice 


. 91.2 


0.57 


0.902 


0.237 


5.10 




0.89 




Jelly 


• 36.3 


0-45 


0.524 


0.175 


32.29 


60.29 


30.52 


49-33 


Pulp 


■ 87.5 


0.75 






6. II 




0.29 




Jam 


• 43-4 


0.48 


0.744 


0.525 


33-44 


42.45 


II 33 


73-38 


Orange : 


















Juice 


• 93 9 


0.36 


0.297 


0.581 


1.52 




2.29 




Jely 


• 314 


0.30 


. 1 7 1 


0.418 


3-95 


65 -59 


62.62 


4.91 


Pulp 


. 86.9 


0.61 


. 686 


0.985 


4.13 




3-33 




Jam 


195 


0.44 


0.433 


0.944 


13-61 


69- 13 


54 23 


21.55 



12 



178 CARBOHYDRATE-RICH FOODS 

preparation of jellies, for it aids in the gelatinization of pectin 
and in the inversion of the sugar. In the latter process a large 
proportion of the added cane-sugar is "inverted'' into non- 
crystaUizing invert sugar. This is an important consideration 
in preparing such products, for otherwise the cane-sugar would 
crystallize and the jelly or jam would be physically unpalatable. 
The following table on page 177 gives the comparative com- 
position of the expressed juice and pulp and of the jelly and 
jams prepared from them. 

Digestion and Utilization of Sugar. — We will confine our dis- 
cussion to the utiUzation of sucrose and its products of hydroly- 
sis, for the quantities of the other sugars ingested are compara- 
tively small. The only important exception is the lactose in 
milk, the source of carbohydrate in the diet of infants. The 
digestion of sugars takes place almost wholly in the intestines. 
They are there transformed, in the processes of digestion, into 
monosaccharides and in that form are completely absorbed. 

Under certain conditions, however, sucrose may be absorbed 
into the system without being first inverted. When excessive 
quantities of a sugar are ingested, absorption takes place more 
rapidly than digestion, i. e., the assimilation limit is exceeded. 
Sucrose which gains access to the blood stream in this way is 
not utilized, however, for it immediately appears in the urine. 
This fact has also been proved by the injection of sucrose into 
the blood when it is excreted almost quantitatively. The 
appearance of sugar in the urine under such conditions is 
termed "glycosuria." An alimentary glycosuria may occur upon 
the excessive ingestion of any of the readily absorbable sugars. 
The quantity which may be ingested at one time without 
causing glycosuria is a rather definite quantity for each indi- 
vidual. The following are average figures: 

• Grams. 

Lactose 120 

Cane-sugar 150-200 

Levulose 200 

Glucose 200-250 

When the ingestion of a sugar is distributed over long periods 
of time and particularly when it is taken with other food, 
greater quantities than these can be given without causing 
glycosuria. Taylor has suggested that the assimilation limit 
of glucose is not as definite a quantity as formerly supposed 
but that it depends upon the capacity of the individual to 
retain it without regurgitation. 

Cane-sugar, when taken in concentrated solution, has a dis- 
turbing effect upon the digestive processes. These disturb- 
ances are likely to arise from the ingestion of candies or sweet 



STARCH 179 

syrups except when accompanied by food or sufficient water. 
The effect has been shown to be a direct irritation of 
the gastric mucosa due to the rapid withdrawal of water, 
causing inflammation and excessive secretion of mucus and 
a highly acid gastric juice. The repeated irritation of the 
stomach may lead to serious gastric disturbances. Investiga- 
tions have shown that with too large an ingestion of sugar 
(120 grams) the emptying of the stomach is delayed. Invert 
sugar does not have as pronounced an effect upon the diges- 
tive processes as sucrose. 

Since sugars are not absorbed in the stomach, when their 
passage is delayed fermentation often takes place. The prod- 
ucts of such fermentation vary — there may be lactic, butyric, 
or alcoholic "fermentation" according to the conditions which 
exist. Lactose has been shown to be less likely to give rise to 
fermentation. 

Sugar is the most concentrated form of carbohydrate food, for, 
in the form in which it is usually ingested it contains very Httle 
water. For this reason and because they are easily digestible and 
assimilable sugars are valuable when it is desired to supply 
food for the performance of work involving a sudden outburst 
of effort; they become available to the tissues in a compara- 
tively short time. Experiments with soldiers have shown that 
they are able to perform a greater amount of work without 
fatigue after the ingestion of sugar than without it. Since 
continued effort is accompanied by a depletion of the carbo- 
hydrate stores, it is necessary, when sugar is being taken for 
an increase of efficiency, to ingest it at intervals during the 
whole period. The fact that sugars are completely absorbed 
is of importance in the construction of a diet in which it is 
desired to supply the energy requirements without producing 
a large fecal mass. 

Valuable as sugar is in certain cases, from a dietetic stand- 
point there is a certain danger in its use. Von Bunge has 
pointed out that the excessive use of sugar in the diet is likely 
to lead to a decrease in the ingestion of vegetable foods and 
to a consequent failure to obtain the inorganic elements, such 
as iron, calcium, phosphorus, etc., which are necessary for 
continued good health. The average diet has been shown to 
be comparatively low in these food constituents and any 
tendency to lower the quantity taken is to be guarded against. 

STARCH. 

Starch is the principal form of carbohydrate in the food of 
man. It is the form in which the plant stores the soluble 



180 CARBOHYDRATE-RICH FOODS 

carbohydrate formed in the processes of photosynthesis 
against the future demands of the embryo or plant itself. It 
is a member of the group of carbohydrates designated as poly- 
saccharides. A starch molecule is composed of a number of 
molecules of glucose which have been united into a complex 
structure in which one molecule of water has been removed 
in the union of two molecules of glucose. 

Upon digestion (hydrolysis) starch is broken down into 
simple compounds — soluble starch, dextrin, maltose, glucose — 
according to the nature and intensity of the digestive process. 
The final product, glucose, is absorbed and used in the body 
or synthetized into a compound, glycogen, which is similar in 
structure and serves as a reserve carbohydrate to the same end 
in the animal economy that starch does in the plant. In the 
plant, starch is stored in the form of fine grains or granules. 
These consist of alternate layers of particles of starch and of 
cellulose, a more dense and complex compound similar to 
starch, arranged in concentric rings. The shape of the gran- 
ule and arrangement of the rings is characteristic of the 
plants in which they are formed. The microscopic appear- 
ance of the starch granule thus becomes a valuable means of 
determining its origin and of detecting the adulteration of 
foods. 

Raw starch is insoluble in cold water. Under the influence 
of heat (or acids) it takes up water, becomes hydrated, swells, 
and becomes semitransparent, forming an opaque solution. 
This is not a true solution but one in which the starch par- 
ticles are suspended in water — a colloidal solution. Careful 
treatment of starch with acids gives a partially hydrated 
product known as soluble starch, the dried form of which is 
soluble — a colloidal solution— in cold water. The hydration of 
starch under the influence of heat and in the presence of water 
causes the starch grains to swell and rupture the surrounding 
cellulose layers. This is the object sought in the cooking of 
vegetables. 

Dextrin is one of the first products of hydrolysis of starch, 
formed by the action of enzymes (digestion), of acids, or of 
heat. Although it still retains the complex structure of starch, 
it is more soluble in water. The carbohydrate of the crust 
of a loaf of bread is composed largely of soluble starch and 
dextrin formed during the baking process. 

The readily soluble and diff'usible products of the h3^droly- 
sis of starch, maltose and glucose, have alread}^ been consid- 
ered in our discussion of sugars. 

Starch itself is readily digested and absorbed. Glucose is 
the end-product of its digestion— the form of carbohydrate 



GRAINS AND THEIR PRODUCTS 181 

present in the blood stream. The digestion and absorption of 
starch extends over a considerable length of time being 
delayed by the associated indigestible cellulose. The result 
is that starchy foods yield glucose to the body over a much 
longer period of time than those containing soluble carbohy- 
drates, sugars. This is in most cases an advantage, particu- 
larly where severe muscular work is to be performed. The 
gradual absorption of the carbohydrate keeps the body con- 
tinually supplied with the most efficient food for the per- 
formance of work yet without depleting the store of glycogen 
before the next meal. 

The digestibility of the various prepared foods, particularly 
bread and potatoes, will be discussed later (pp. 190 and 192). 



GRAINS AND THEIR PRODUCTS. 

This group of foods includes the seeds of various plants 
such as barley, buckwheat, corn or maize, oats, rice, rye, and 
wheat, and the products manufactured from them. Grains 
are harvested in the partially dried state and contain, there- 
fore, a lower percentage of water (10 to 12 per cent.) and a 
higher percentage of carbohydrate, protein and fat than the 
fresh grain. Starch is the predominating food-stufF (65 to 75 
per cent, of the dried grain). Small quantities of sugar and 
cellulose are present. The protein content is rather high 
(10 to 12 per cent.) and a number of different kinds are pres- 
ent. The predominating proteins, such as the alcohol-soluble 
protein, gliadin, and the glutelin, glutenin of wheat, are of a 
different type from those found in flesh foods. The nutritive 
value of vegetable proteins has been discussed (p. 116). The 
fat content of grains may be rather high, oats and corn con- 
tain as much as 8 per cent.; the values average between 0.5 
and 8 per cent., according to the kind of grain. The fat of 
the grains has a low melting-point and exists as an oil. 
Approximately 2 per cent, of ash is present in grain. This is 
distributed chiefly in the outer layers of the kernel and the germ. 
The tables on pages 182 and 186 give the composition of the 
various whole grains and of the flours prepared from them. 

Composition of Various Whole Grains as Marketed by the Farmer. 







Protein 




Carbo- 








Water, 


(Nx6.25), 


Fat, 


hydrate, 


Fiber, 


Ash, 




per cent. 


per cent. 


per cent. 


per cent. 


per cent. 


per cent. 


Barley 


10.85 


11.00 


2.25 


69 -55 


3-85 


2.50 


Com . 


10.75 


10.00 


425 


71-75 


1-75 


1.50 


Oats . 


10.06 


12.15 


4-33 


57-93 


12.07 


3-45 


S7.^ 


10.50 


12.25 


1.50 


71-75 


2.10 


1.90 


Wheat 


10.60 


12.25 


1-75 


71-25 


2.40 


1-75 



182 



CARBOHYDRATE-RICH FOODS 



Composition of Prepared Cereals. 





-g 


CO 


^ 


^ . 


1 








1 











►h 


^0 

H 






a o 


a> 


^ 


a 


<0 






i 


3fe 


0. 


^fe 


IH- 


A 


^ 




s 




P^ 


6^ 


.0 


4 
< 


§0. 


Barley, pearled . 


II. 9 


10.5 


2.2 


72.8 


6.5 


2.6 


1603 


Buckwheat flour 


13-6 


6.4 


1.2 


77-9 


0.4 


0.9 


1577 


Cornmeal, granular 


12-5 


9-2 


1-9 


75-4 


1 .0 


I.O 


1620 


Oatmeal . 


7-3 


i6.i 


7.2 


67.5 


0.9 


19 


1811 


Rice .... 


12.3 


8.0 


0.3 


79 


0.2 


0.4 


1591 


Rye flour . 


II. 4 


13 6 


2.0 


71.5 


1.8 


1-5 


1626 


Wheat flour . . 


12.0 


II. 4 


I .0 


75 I 


0.3 


0.5 


1610 



go 

o 

28 

29 

28 

25 
29 

28 
28 

With few exceptions the grains are rolled or milled before 
they are used in the preparation of food. In the various pro- 
cesses certain portions of the grain are removed, particularly 
the outer layers of the kernel and the germ. The accompany- 
ing data related to the polishing of rice gives the important 
changes in chemical composition during milHng. 

Chemical Composition of the Honduras Type of Rice after Various 
Milling Processes of Modern Rice Mills.^ 

Constituents (per cent.). 





1 


4 
< 




a) 

u 



.a 


u 

Ph 


1 

fin 


a 
1 


1 
1 

1 


Rough rice .... 
After removal of hulls . 
After removal of bran and 


11.27 
12.32 


540 
1. 18 


1.58 

I 79 


8.67 
0.99 


7.48 
8.57 


590 
2.42 


8.43 
9.78 


6.65 
2.75 


most of the germ . 
After further removal of 


12.56 


0.53 


0.40 


39 


7-79 


I .90 


8.91 


2.17 


bran (pearling) 
After polishing . 
Coating 


12.50 
11.89 
12.02 


0.47 
0.36 
0.40 


0.28 
0.25 
0.21 


0.30 
0.30 
0.26 

73.00 


7.88 
8.06 

7-75 


1-53 
1.80 
1.66 


9.00 

915 

8.81 


1-75 
2.04 
1.88 


Total loss2 . . . 


66.00 


85.00 


10.00 


32.00 


10.00 


32.00 



Barley. — Barley is not used extensively for human food in 
this country. As "pearled barley/' prepared by removing the 
germ and the greater portion of the bran, it is used in soups. 
Barley water, prepared from "patent" barley flour is used in 
infant feeding and in the diet of the sick room. "Patent" 
barley flour is finely ground pearl barley or barley which has 
been more thoroughly poHshed than pearl barley. 

Buckwheat. — Buckwheat, although ordinarily classed with the 
cereals, does not belong with them according to its botanical 
classification. Its use is confined chiefly to the preparation 



1 Bulletin 330, U. S. Dept. Agr., 1916. 



2 On a moisture-free basis. 



GRAINS AND THEIR PRODUCTS 183 

of pancakes, a hot breakfast cake. In the preparation of 
buckwheat flour the outer covering is removed and the remain- 
ing portion rolled and bolted as in the preparation of wheat 
flour. A rather coarse bolting cloth is used which permits a 
certain amount of the middlings (see flour) to pass through. 
A white grade of flour, bolted over a finer cloth, is poorer in 
protein and fat. Buckwheat is rich in "gluten" the water- 
insoluble, elastic protein mixture which is the basis of a batter 
capable of considerable expansion; thus giving a Hght cake 
when baked. 

Com. — Indian corn or maize differs in composition from the 
other grains with the exception of the oat, in that it has a 
high percentage of oil. Corn products are not readily leav- 
ened because of their low gluten content; wheat flour is often 
added to rectify this defect. Corn and corn products show 
the same digestibility as other grains. There are a number of 
varieties of corn. From a dietetic stand-point distinctions are 
made among them chiefly on the basis of their use for food: 
the variety used for cornmeal flour or hominy is field corn; 
for *' popping", popcorn; for use in the green state, green or 
sweet corn. Field corn is harvested in the semidry state; it 
is marketed for human food as cornmeal, corn flour, hominy, 
and corn starch. 

Cornmeal or corn flour is prepared from the whole grain. 
"Old process" cornmeal is made by grinding the entire kernel 
and then separating the larger particles of bran with a sieve; 
this method gives a flour containing the germ and a certain 
amount of bran in addition to the starchy portion of the ker- 
nel. This product is rich in oil and protein. It is difl&cult to 
keep such meal, for the oil tends to become rancid. By more 
careful milling and bolting both the germ and bran are removed, 
yielding a product which is low in protein, ash, and particularly 
oil. This flour may be kept for a longer time than the "old 
process" cornmeal without becoming rancid. But the advan- 
tage is gained at the expense of nutritive value and accessory 
substances. 

Yellow and white cornmeal are prepared from yellow and 
white varieties of corn respectively. Any preference shown for 
one or the other of these meals is a matter of taste, for there is 
essentially no difference between them. 

Corn starch is also prepared from maize. In its preparation 
the corn is steeped in warm water; the swollen grain is passed 
through coarse mills to disintegrate the kernel without break- 
ing the germ; the germ is removed by a process of differential 
sedimentation in which the oily germ floats off at the top 
while the starch granules and other particles settle to the 



184 CARBOHYDRATE-RICH FOODS 

bottom of the separator; the sedimented starch granules and 
associated hulls are reground and passed over a fine sieve to 
remove the hulls, and the starch finally purified by fractional 
sedimentation. Purified starch is sold as such or after being 
hydrolyzed with acids and steam under pressure, as glucose 
(p. 176). 

Green or sweet corn is characterized by its high sugar con- 
tent. It is eaten in the green state, hence its place in the diet 
is with succulent vegetables. Large quantities of sweet corn 
are canned, thus making it available throughout the year. 

Oats. — Oats, Hke corn, have a high fat content. The prod- 
ucts prepared from oats usually contain the whole kernel and 
are therefore highly nutritious. The use of oatmeal by the 
Scotch has won for it a reputation as a stimulating and muscle- 
building food which is perhaps overestimated in comparison 
with other grain products of a similar character. Oat pre- 
parations do not leaven readily, since little gluten is present. 
Oatmeal is used largely in the preparation of porridges and to 
a smaller extent in bread and cakes. Because of the presence 
of the germ in oat products the percentage of purine bases 
is higher than in products prepared from the other cereals 
in which the germ is removed; for this reason they are ex- 
cluded from a purine-free diet. Studies of the digestibility 
and availability of oats show them to be fully as well utilized 
as bread. 

Rice. — Rice is particularly rich in carbohydrate. It is used 
among certain people as the principal constituent of the diet, 
which is therefore deficient in protein and fat. The lack of 
protein accompanying a rice diet has been assigned by cer- 
tain investigators as the cause of the inferior physical and 
mental development of these races. 

Rice is supplied in three forms: unhuUed; "cured," free 
from the husk but still retaining the bran; and polished. The 
polished rice is sometimes coated with talc, paraffin or glu- 
cose to improve its appearance. In the processes of polishing 
the outer layers of bran are removed and in so doing a large 
portion of the mineral matter, particularly phosphorus, is lost. 
In polishing rice some important dietary constituents (acces- 
sory substances) are also removed. People who use polished 
rice as the major constituent of the diet tend to develop beri- 
beri, a disease which affects the nervous system. The inges- 
tion of unpoHshed rice or the addition of foods containing the 
accessory food substances will cure beriberi. 

Rice is as readily and thoroughly digested as other grains. 
The small amount of cellulose it contains makes it a desirable 
food when the fecal residue is to be kept as low as possible. 



GRAINS AND THEIR PRODUCTS 185 

This applies particularly to polished rice. Because of the low 
protein and fat content it is advisable to eat protein-rich foods, 
such as eggs, cheese, and milk, with it. Vegetables should be 
used with rice, particularly with polished rice, because of its 
low content of ash and accessory food substances. 

Rye. — Rye is used extensively in the preparation of bread. 
In composition it closely approaches wheat. Its proteins are 
in slightly different proportions; it has considerable protein cor- 
responding to the ghadin of wheat, but the other constituent of 
gluten, glutenin, is lacking. Bread made from rye flour is darker, 
the texture is more dense, and it contains rather more nour- 
ishment than wheat bread. The digestibility of rye bread is 
approximately equal to that of white bread. Bread made from 
flour from which the bran is not removed is not as thoroughly 
digested as the bolted flour. 

Wheat. — Wheat is used more extensively in the human 
dietary than any other grain. Chemical analysis does not 
indicate any particular superiority of wheat over other grains, 
nor is it found to be more digestible. It is the appearance 
of the prepared product and the ease with which it may be 
leavened that makes wheat prized above the other grains. 
The fact that wheat flour is comparatively rich in the water- 
insoluble proteins present in the gluten, the alcohol-soluble 
gliadin and the alkali-soluble glutenin, makes it the preeminent 
bread-making grain. For the elastic adherent mixture, gluten 
stretches and holds the expanding bubbles of gas produced by 
the leavening agents. It is the coagulation around these bubbles 
which gives to bread the porous structure in the baked product. 
With wheat or its products as the basis, the addition of various 
substances enables the housewife to prepare an endless variety 
of dishes, and thus use this valuable food without creating a 
distaste for it because of the monotony of the diet. 

In spite of its general adaptability to variety in preparation 
wheat is consumed largely in one form, bread. Rye is the 
only other grain which approaches wheat in its bread-making 
properties. Rye bread is, however, a less attractive product 
for it is darker and slightly more sticky than wheat bread. 

Wheat is seldom eaten without a certain amount of mechan- 
ical preparation and modification. The majority of the wheat 
is consumed in the form of products made from flour. The 
crushed or whole kernel is often used as a breakfast food after 
it has been swollen and the starch partially cooked by boiHng. 
A recent preparation has been put on the market in which 
the whole wheat kernel is subjected to pressure, heated, then 
allowed suddenly to expand, producing a change in the struc- 
ture similar to that obtained in popped popcorn. 



186 CARBOHYDRATE-RICH FOODS 

Flour is prepared by a process of grinding and sieving by 
which the kernel is pulverized and the outer coverings or bran 
and the germ are separated from the inner portion, which is 
rich in starch and gluten. Formerly the wheat was ground in 
one process and the resulting products sifted and graded 
according to their fineness of division. This gave three gen- 
eral grades: white flour (finest), middlings (which contain 
some fine particles of the coarse outer material) and bran. 
Middlings obtained from the roller process diff'er from the 
above in that they contain very little bran. The present 
method is to crush the grain between a series of rollers which 
reduce the size of the particles gradually until the desired tex- 
ture is obtained. Between the diff^erent sets of rollers are 
sieves to separate the finely divided flour from the coarser 
bran and germ. Early in the rolling process a white flour poor 
in gluten, called "break" flour is separated; as the grinding 
becomes finer more and more of the gluten-rich flour with a 
yellowish color, or the middlings is obtained. A mixture of 
these two general classes of flour, "breaks" and middhngs give 
a flour containing the proper amount of gluten for bread- 
making. The highest grades of flour are known as "patent," 
"standard patent flour," "straight grade flour," "first clear." 
The lower grades of flour are designated "second clear," 
"bakers' flour" and the lowest grade is called "red dog." 
The highest grades of flour are light in color and contain more 
gluten and show a better granulation than the lower grades. 
In the latter, the protein content is higher, but the gluten is 
less elastic and not as satisfactory for bread-making purposes. 
The best test of a good flour is its baking properties. 

Analysis of Wheat and the Products of Roller Milling (United 
States Department of Agriculture). 







Protein 




Carbo- 






Water, 


(Nx5.7), 


Fat, 


hydrate, 


Ash, 


Milling products. 


per cent. 


per cent. 


per cent. 


per cent. 


per cent 


First patent flour . 


10.55 


11.08 


115 


76.85 


0.37 


Second patent flour 


10.49 


II. 14 


1.20 


76.75 


0.42 


First clear grade flour . 


10.13 


13-74 


2.20 


73 13 


0.80 


Straight or standard patent 












flour 


10.54 


11.99 


I. 61 


75-36 


0.50 


Second clear grade flour . 


10.08 


1503 


3-77 


69 


37 


1-75 


"Red dog" flour 


9.17 


18.98 


7.00 


61 


37 


3-48 


Shorts 


8.73 


14.87 


6.37 


65 


47 


4-56 


Bran 


9-99 


14.02 


4-39 


65 


54 


6.06 


Entire wheat flour . 


10.81 


12.26 


2.24 


73 


67 


1.02 


Graham flour .... 


8.61 


12.65 


2.44 


74 


58 


1.72 


Wheat ground in laboratory 


8.50 


12.65 


2.36 


74 


69 


1.80 


Germ 


8.73 


27.24 


11.23 


48 


09 


4.71 



There are a number of varieties of wheat: spring, winter, 
soft, and hard. By the use of these and by diff'erent methods 



GRAINS AND THEIR PRODUCTS 187 

of manipulation a number of grades of flour are produced 
which vary chiefly in their gluten content. In baking these 
diff'erences assume more or less importance. From a nutri- 
tive point of view, however, it is the relative proportion of the 
inner portion of the kernel, bran, the outer covering, and the 
germ which is of importance. 

Certain grades of flour have distinctive names under which 
they are sold in commerce. Graham flour is composed of the 
carefully ground, unbolted entire wheat kernel. As' such it 
contains all the constituents of the wheat, the bran, the germ, 
and contents of the endosperm (starch and gluten). This 
flour derives its name from Sylvester Graham who advocated 
the ingestion of the whole wheat for both economical and 
dietetic reasons. The greater cellulose content of the bran 
renders bread from such flour less digestible. The added intes- 
tinal irritation, the bulk derived from the particles of indi- 
gestible bran, and certain substances present in the bran and 
germ have mild laxative properties. 

Entire wheat flour is made of wheat from which the greater 
part of the outer covering, or bran, has been removed. It 
contains the germ with its added fat and protein content in 
addition to the usual constituents of flour. The increased 
nutritive value protein — fat and ash — of the flour is of economic 
importance. 

Gluten flours are prepared by removing the greater part of 
the starch from ordinary flour and are supplied in various 
grades, according to the quantity of gluten present. They are 
of particular value as food for diabetics. Gluten flours are 
discussed further in connection with diabetes. 

Bread. — The term bread is usually applied to the baked, 
leavened preparation of wheat flour. It may, however, include 
similar preparations of all forms of finely divided grains, such 
as rye bread or corn bread. When the added ingredients used 
with flour assume importance with regard to flavor and tex- 
ture, the mixture is no longer distinguished as bread. Thus 
sugar, butter, eggs, milk, spices, are used with flour in the 
preparation of cakes, puddings, and pastries. 

Bread in the sense ordinarily used is a combination of white 
flour, water, salt, and yeast which have been leavened as the 
result of the growth of the yeast. In this process carbon 
dioxide is formed and the mixture "rises," assuming a sponge- 
like structure. This ''sponge" is kneaded with the addition 
of flour, divided into appropriate masses, permitted to rise 
again and, at the proper time, baked. In the process of bak- 
ing heat causes a further expansion of the carbon dioxide and 
air and by coagulating the proteins retains the sponge-like 



188 CARBOHYDRATE-RICH FOODS 

structure. Various changes take place in the chemical com- 
position of the flour during the leavening process. A cer- 
tain amount of sugar is converted into carbon dioxide and 
alcohol; during baking there is a loss of water and fat, the 
protein is coagulated, the starch grains are broken, and at the 
outer surface particularly starch is converted by dry heat into 
soluble starch and dextrin. The partial caramelization of the 
starch and dextrin produces the delicate brown color of a 
well-baked loaf. 

Leavening may be accomplished in a number of ways — 
with yeast (enzj^matic) which is supplied in both moist (com- 
pressed yeast) and dried condition; by mechanical incorpora- 
tion of air; or by the evolution of gas as the result of chemical 
action (baking powder). When yeast is used the carbon diox- 
ide is produced at the expense of the constituents of the flour, 
the starch is partially converted into simpler products in addi- 
tion to alcohol, and certain amounts of organic acids, such as 
lactic or acetic, which in quantity are said to injure the flavor 
of bread. 

The simplest form of aeration with mechanical incorpora- 
tion of gas is that produced by *' beating up" a mixture of 
flour and water. The entrapped bubbles of air swell and pro- 
duce, when baked, porous though rather dense biscuit or 
bread. Unleavened bread is used in certain religious festi- 
vals. In the commercial preparation of bread, water satu- 
rated, under pressure, with gas is sometimes mixed with flour. 
When the pressure is released the dough swells; it is then 
baked. This is called aerated bread. 

Baking Powders. — Baking powders will leaven dough more 
quickly than will yeast, in a few minutes, instead of in six to 
ten hours. All baking powders depend in principle upon the 
interaction between a carbonate and an acid. Sodium bicar- 
bonate (saleratus or baking soda) is the most common source 
of carbon dioxide. The old method of making certain breads 
with sour milk and soda often resulted in a semifailure because 
of the varying degrees of acidity of the milk. The baking 
powders now supplied have the acid and alkali so balanced 
that there is complete neutralization. Preparations vary 
chiefly in the nature of the acid constituent or its equivalent; 
thus we have the *' tartrate" (tartar), acid potassium tartrate 
or tartaric acid powders; the phosphate (calcmm acid phos- 
phate) powders, and the alum powders (a sulphate of 
aluminum). These salts when mixed with bicarbonate are 
relatively inert in the dry state but in the presence of water 
react readily to yield carbon dioxide. 

There are certain objections to the use of baking powders 



GRAINS AND THEIR PRODUCTS 189 

in that the salts resulting from their reactions may be deleter- 
ious to the health through their action on the system in gen- 
eral or to their laxative effect. While it is certain that excessive 
doses of these salts are harmful it is difficult to determine 
whether or not small amounts, such as are ingested in breads, 
are detrimental. 

Rolls, Biscuits, Muffins, etc. — Rolls are similar to bread 
except that they usually contain more added fat in the form 
of lard or butter and sometines more sugar. They differ 
Httle in composition from bread. In baking they are ordinarily 
made into small loaves or *' rolls" and have more crust in 
proportion to their size than bread. Such breads are often 
used while hot or warm. 

The ordinary baking powder biscuit differs from the roll 
in that it is leavened with baking powder and contains 
more shortening, as lard or butter. The effect of the short- 
ening is to render the gluten less tenacious. Biscuits are, 
therefore, readily broken into pieces when hot. 

Muffins are similar to biscuits; they usually contain egg in 
addition to the other ingredients. 

Rolls, biscuits and muffins are often referred to as indiges- 
tible. This indigestibility is ascribed in part to the added fat 
and in part to the fact that since they are served hot, they 
are eaten rapidly and without sufficient mastication, thus 
yielding a sodden mass which does not pass readily from the 
stomach. Experiments have shown the relative availabiUty of 
the protein, fat, and carbohydrate of these foods to be fully as 
complete as those of bread. 

Biscuits, Crackers. — The term biscuit is used commonly 
to designate the hard, dry breads baked in thin layers and 
prepared with the addition of little or no baking power. 
These are sold in various forms depending upon the ingred- 
ients used in their manufacture. They are held to be very 
digestible, no doubt because of their dryness and to the com- 
plete salivation and mastication necessary in. eating them. 

Cakes. — Cakes are sweetened breads in which eggs, milk, 
flavoring and spices and considerable shortening, such as 
butter and lard, are used. They are very "rich" foods in that 
they contain more fat and protein than the breads. 

Breakfast Foods. — Certain specially prepared grains are 
sold as breakfast foods. These are usually patented prepara- 
tions. Among them will be found representatives of all the 
more important grains. The changes produced are chiefly of 
a mechanical nature associated with a certain amount of 
chemical change resembling the natural processes of diges- 
tion. The changes are in general of a fermentative nature, 



190 



CARBOHYDRATE-RICH FOODS 



such as those produced by the action of malt or yeast and the 
action of heat upon either the moist or dry grain. Condi- 
ments, such as sugar and salts, are sometimes added. Those 
foods which are cooked are sold for direct consumption; the 
others must be subjected to prolonged cooking before they 
are ready for the table. 

Macaroni. — Macaroni is a preparation of a highly glutenous 
wheat flour and water. It is molded into various forms and sold 
under diflPerent trade names, as spaghetti, macaroni, and noodles. 
A special type of wheat, durum wheat, is used. The relative 
composition of macaroni will be found in the accompanying 
table. 

The composition of some of these preparations is given in 
the following table: 

Composition of Typical Wheat Products. 









^• 


i 


1 


"^ 


a.2J 

'0 

2"^ 


8 






II 


tD 




1 



a; 


1". 

>T3 


^.i 




i 


Jfe 


a 


Z^ 


u 


a 


a 


ii 




"c3 


oa 


"c3 


sa 


^ 


J3 


sa 


go 




PL, 


fe 





E 


< 


^ 





Breakfast food: 


















Cracked Wheat 


lO.I 


II. I 


1-7 


75-5 


1-7 


1.6 


1635 


28 


Shredded Wheat 


8.1 


10.5 


1-4 


77-9 


1-7 


2.1 


1660 


27 


Macaroni . 


10.3 


13-4 


0.9 


74.1 




1-3 


1625 


28 


Rolls, Vienna 
Bread: 

White . . . . 


371 


8.5 


2.2 


56.5 


0.4 


I.I 


1270 


36 


35-3 


9.2 


13 


531 


0.5 


I.I 


1182 


38 


Whole wheat . 


38.4 


9-7 


0.9 


49-7 


1.2 


1-3 


1113 


41 


Crackers, soda 


5-9 


9.8 


9.1 


731 


0.3 


2.1 


1875 


24 


Cake, cup 


15-6 


5-9 


9.0 


68.5 


0-3 


1 .0 


1716 


26 



The digestibihty and nutritive value of bread, particularly 
the comparative digestibility of white bread and the whole 
wheat or Graham breads assumes considerable economic impor- 
tance with regard to the diet of the poor and there has been 
a great deal of controversy over the question. Comparative 
studies of the two forms of bread have demonstrated a lower 
digestibihty of the protein and carbohydrates of entire wheat 
and Graham flours. 

Celluloses. — Celluloses form a large portion of the cell wall 
of plants. They are polysaccharids having a more complex 
structure than the starches. Celluloses diff"er according to 
whether they are composed of glucose or some other sugar, 
as pentose or galactose. These carbohydrates are very 
insoluble in water and more diflRcult to hydrolyze than starch, 
and are practically indigestible for man. It is the indigestibility 
of the celluloses which makes vegetables and fruits a valuable 
means of adding bulk to the intestinal mass with the resultant 



POTATOES 191 

stimulation of peristalsis. Cellulose is also largely responsible 
for the low utilization of vegetable foods. 

Hemicelluloses differ from true celluloses in that they are 
hydrolyzed by dilute acids. Of this class the sea-weed, agar 
agar and Iceland moss are of dietetic and therapeutic impor- 
tance. Because of their comparative indigestibility and their 
abihty to absorb and hold water they yield a soft fecal mass 
which may be easily evacuated. 

Potatoes. — The true, "Irish", potato, as well as the sweet 
potato, is used to a large extent as one of the important sources 
of carbohydrate. We will therefore discuss these foods here, 
although they possess properties which might place them 
with the succulent vegetables, more valuable for their salts 
and water. Bananas are, from a nutritive point of view, com- 
parable with potatoes; they are, however, ordinarily classed 

with fruits. 

Composition. 





C3 








1 




to 


11 

IS 


13 




^ 


Ah 


f^ 





p^ 


<1 


tH 





Potatoes: 


















Irish . . 


• . 78.3 


2.2 


O.I 


18.4 


0.4 


1.0 


378 


120 


Sweet . . 


. 69 . 


1.8 


0.7 


27.4 


1-3 


I.I 


558 


81 


Bananas . 


• . 75-3 


1-3 


0.6 


22.0 


I.O 


0.8 


447 


lOI 



The chemical composition of potatoes varies somewhat 
according to the different varieties, and to the portion of the 
country in which they are grown. The average potato con- 
tains 18 to 20 per cent, carbohydrate (largely starch); 2 to 
2.5 per cent, protein; practically no fat — o.i per cent.; and 
75 to 80 per cent, water. The greater proportion of the carbo- 
hydrate present in potatoes is starch; but there is also a small 
proportion — 0.3 to 0.2 per cent, of sugars and glucose. The 
sugar content of young or early and old, sprquted potatoes is 
greater than that of the mature potato. The tuber receives 
carbohydrate as glucose and converts it to starch; later as the 
potato sprouts the starch is reconverted into glucose for the 
use of the growing shoots. The protein of potatoes is usually 
expressed as the nitrogen value times 6.25. We know that in 
the case of the potato this does not entirely represent protein, 
for there is a considerable quantity of non-protein, nitrogenous- 
containing material, particularly asparagin. The ash of potato 
contains considerable quantities of calcium, phosphorus and 
iron. The total ash is predominately basic. 

Potatoes are rich in the water-soluble accessory substances 



192 CARBOHYDRATE-RICH FOODS 

(vitamines). The use of potato water as an antiscorbutic has 
been suggested for infants in place of the more expensive 
orange juice. 

The sweet-potato plant does not belong to the same botan- 
ical family as the Irish potato. This tuber resembles the 
latter, however, in its general chemical composition and is 
usually associated with it dietetically. The sweet potato is 
roughly similar in composition to the Irish or white potato; 
it contains a little less water — averaging 70 per cent. — and a 
slightly higher percentage of starch, sugar and protein, aver- 
aging 24 per cent., 5 to 8 per cent., and i per cent., respectivel}^. 
The effect of the storage of sweet potatoes is to increase the 
sugar content. The material designated as ** sugars" is chiefly 
sucrose with a small amount of invert sugar (glucose and 
fructose). 

Because potatoes are an important source of mineral mat- 
ter it is essential to conserve this as much as possible. In the 
process of paring as much as 20 per cent, of the potato is lost; 
furthermore, a large proportion of the protein and mineral 
matter is in the layers beneath the skin. The skin tends to 
prevent the loss of protein and salts. Peeled potatoes when 
soaked in water and then boiled in water lose a considerable 
proportion of their salt content, approximately ten times 
as much as when they are cooked without removing the 
skins. When they are baked or steamed the loss is compara- 
tively small. If the cooking is begun in hot water the loss of 
material is less than when the cooking is commenced in cold 
water. 

Potatoes when properly cooked are quite digestible; approx- 
imately 92 per cent, of the carbohydrate and 70 per cent, of 
the protein is absorbed. They have been found to leave 
the stomach quite rapidly — more so than bread. The ease 
with which potatoes are digested varies with the mode of 
preparation. Boiled or baked mealy potatoes pass more 
readily from the stomach than waxy potatoes or potatoes 
which have been fried or prepared with fatty substances as 
in salads. Finely divided pieces of potatoes pass out of the 
stomach more readily than larger pieces. The low fat con- 
tent of potatoes indicates the addition of fatty substances after 
they are cooked when they are used as the principal source of 
food. 

Because of the low cost of potatoes they have been advo- 
cated as the chief article of diet in some countries. There is 
a certain amount of objection to this because of the quantity 
which must be eaten to supply the necessary energy and pro- 
tein — approximtely 6.5 pounds or 3 kilos. Such quantities 



POTATOES 193 

would contain a smaller proportion of protein than is deemed 
necessary by some. The energy value is, moreover, roughly a 
third that of white bread. Hindhede, of Sweden, who has 
advocated the adoption of a potato diet, has shown that the 
body may be maintained in perfect health over long periods 
of time on a diet of potatoes, milk, oleomargarine, green vege- 
tables, and fruit, provided the total diet has an energy value 
in proportion to 3000 Calories for a man of 70 kilos (164 
pounds). 



13 



CHAPTER XIII. 
FAT-RICH FOODS. 

Animal or plant fat is a mixture of true fats and lipoids. 
These two substances are classed together under the term 
^^lipin' because of similar physical or chemical properties. 
The true fats are glycerol esters of fatty acids; they are named 
according to the acid from which they are derived by substi- 
tuting "in" for ''ic" of the name given the fatty acid, thus: 
Butyrin, olein, stearin, or tributyrin, triolein, tristearin for 
fats formed from butyric, oleic, and stearic acids. Fats are 
widely distributed in the plant and animal kingdom and are 
one of the most valuable sources of energy to the body. Asso- 
ciated with fat are the lipoids, or fat-Kke substances related 
by composition and solubility. In their chemical constitution 
lipoids may differ entirely from fats as cholesterol, or may be 
compounds of fat with other radicles as in the case of lecithin. 
The lipoids are constituents of all cells and particularly of the 
highly organized nervous tissue. Our knowledge of their 
occurrence and functions is, however, very Hmited. 

The fats most commonly found in food are those derived 
from the saturated fatty acids, butyric acid, caproic acid, 
caprylic acid, capric acid, lauric acid, myristic acid, palmitic 
acid and stearic acid, and from the unsaturated fatty acids, 
oleic, linoleic, and linolenic acids. Of the saturated fatty acids, 
the first members of butyric and caprylic acids are liquid at 
ordinary temperatures, while the others are solid: the melting- 
point increases with the complexity of the molecule. The 
unsaturated fatty acids and the glycerol esters, fats, are 
liquid at ordinary temperatures. 

Food fats are mixtures of these individual fats. Those of 
animal origin are composed largely of olein, palmitin, and 
stearin. The fluidity or solidity of any particular fat depends 
upon the relative proportion of these. The more solid fats 
contain a greater amount of palmitin and stearin, while the 
softer fats contain more olein. 

The fat of various animals is more or less characteristic for 
each species. Warm-blooded animals have harder fat than 
cold-blooded animals, such as fishes; and of the land animals 
herbivora have, as a rule, harder fats than carnivora. The 
composition of subcutaneous fat appears to be determined in 
part by the external temperature of the air surrounding the 



FAT-RICH FOODS 195 

body. The facial fat of individuals exposed to the weather is 
richer in olein and has a lower melting-point than of those less 
exposed. The fat of those portions of animals which have a 
poor blood supply, such as the back, is richer in olein and has 
a lower melting-point than fat in other parts thoroughly 
warmed by the blood. The fat of beef animals has been found 
to become richer in olein with age, fatness, and nearness to 
the surface of the body. 

Butter contains a variety of fatty acids — all of those men- 
tioned above in the saturated fatty acid series and oleic and 
butyric acids. The latter acid, while not the most important 
from a quantitative point of view, is most characteristic. The 
vegetable oils contain more of the unsaturated fat compounds 
than animal fats. 

Certain fats — milk fat and the fat of egg yolk in particular — 
occur in a finely divided state or emulsion. Such fats are 
readily digestible because of the size of the fat particles and 
great surface exposed to the action of the digestive enzymes. 
Emulsification may be produced artificially by thorough agita- 
tion of fat with water or by the addition of protein material, 
certain carbohydrates, gum tragacanth, or of soaps. Alkahs 
when added to fats form soaps which in turn aid in emulsifi- 
cation. Mayonnaise dressing, in which comparatively large 
quantities of oil are changed from the liquid state to a semi- 
solid form, is a case of emulsification in the presence of protein 
material. 

Fats are as readily digested and absorbed as proteins and 
carbohydrates. In the process of digestion and absorption 
they are emulsified and broken down into fatty acids and 
glycerol, absorbed into the intestinal wall and in part at least 
resynthetized into fat. The presence of fat tends to delay 
the passage of food from the stomach. The "indigestibility" 
of fatty foods in the sense of the "ease" of digestion is to be 
ascribed in part to this fact. The presence of fats in food, 
particularly of those having high melting-points which are not 
liquefied in the stomach at body temperature, tends to retard 
peptic and saHvary digestion. Fats form a protective coating 
over the particles of protein and starch and prevent their partial 
digestion, thus increasing the extent of digestion necessary 
in the intestine. The effect of cooking foods in fat is to form 
a similar layer of fat over the surface of the food particles. 
This applies particularly to the ordinary process of frying, in 
which heavy fats are often used; cooking in deep fat results 
m the formation of an impervious layer on the outside of the 
food which prevents the further entrance of fat. The partial 
oxidation of fats which takes place in cooking, particularly in 



196 FAT-RICH FOODS 

frying, leads to the formation of substances which may be 
irritating to the ahmentary tract. 

The retarding action which fats exert upon the passage of 
food from the stomach has been found to be beneficial in the 
case of the relatively indigestible vegetables, for by subjecting 
them to a more prolonged contact with the digestive juices 
their digestion is more complete. Vegetables to which a soft 
fat, such as butter, has been added, after cooking, have been 
found to be more thoroughly digested than those cooked in 
fat. Studies of the utilization of fat have shown that ordi- 
nary fats are readily absorbed, approximately 97 per cent, of 
the ingested fat. 

Feces obtained from a fat-poor diet may contain more fat 
than is found in the food ingested. On a milk diet under 
normal conditions the fecal fat melts at 50° to 51° C, while 
the fatty acids of butter melt at 43° C; in diarrhea the fecal 
fat has the same melting-point as milk fat. These facts indi- 
cate that considerable fat is excreted or secreted into the 
intestines from the body in the process of digestion. 

The melting-point of fat affects its digestibility. Those 
fats whose melting-points are close to the temperature of the 
body are Hquefied in the ahmentary canal, readily emulsified 
and digested in the intestines, and show practically complete 
absorption. The more sohd fats are, on the other hand, emul- 
sified with greater difficulty and their digestion is less com- 
plete. Certain fat-like substances, such as paraffin oil and 
lanolin, are not absorbed at all; it is for this reason that 
paraffin oils are used to relieve constipation. These facts have 
been brought out in the following table (Munk and Arnshink) : 

Melting- Percentage 

point, loss in 

Fat. ° C. feces. 

Stearin 60 91-86 

Stearin and almond oil 55 10.6 

Spermaceti . 53 31.0 

Mutton fat 50-51 9.2 

Mutton, fatty acids 56 13-20 

Lard 43 2.6 

Pork fat 34 2.8 

Goose fat ^5 ^ • 5 

Olive oil fluid 2 . 3 

Langeworthy and Holmes^ compared the relative digest- 
ibility of butter, lard, beef and mutton fat when fed with a 
uniform mixed diet of blanc mange, wheat biscuit, fruit and 
sugar. In general the digestibility decreased with an increase 
in the melting-point of the fat. The following table contains 
data demonstrating this: 

^Langeworthy and Holmes: U, S. Dept. Agric, 1915, Bull. No. 310. 



UTILIZATION OF FATS 197 

Comparison of Digestibility and Melting-point. 

Coefficient of Melting- 
digestibility, point, 
Fat studied. per cent. ° C. 

Butter fat 97 32 

Lard 97 35 

Beef fat 93 45 

Mutton fat 88 50 

In the processes of metabolism both fat and carbohydrate 
are used chiefly in the production of energy. Their role in 
the structure of the body, while Httle understood, is highly 
important; this is particularly true of the lipoids, lecithin and 
cholesterol, which are constituents of the outer surface of all 
cells. As a source of energy fats and carbohydrates may, in 
general, be used interchangeably. It seems necessary, how- 
ever, that a certain amount of carbohydrate be present in the 
food for the normal continuance of the metabolic processes. 
The entire absence of carbohydrate tends to produce certain 
disturbances, among which acidosis is the most prominent 
indication. The minimum quantity of carbohydrate needed is 
not known; that it may be comparatively low is illustrated in 
the case of the Eskimo whose diet is essentially fat and pro- 
tein and in which practically the onl}^ source of carbohydrate 
is the glycogen contained in meat. 

Although carbohydrate appears to be indispensible in the 
diet, the presence of fat (lipins) is also essential. Studies of 
growing animals have shown that certain animal fats, e. g., 
kidney fat, egg yolk fat, butter fat, are the more satisfactory 
than others or than plant fats for the continuance of growth. 
The advantage apparently does not reside in the purified fat 
itself, such as tristearin, or triolein for these are without effect. 
It is known that there are substances associated with fat which 
are important for growth and that the absence of these from the 
diet result in pathological conditions. Such substances as the 
accessory food substances, '*fat soluble A" of McCullum, which 
the body apparently cannot synthetize and must therefore 
obtain them from the food are present and necessary. It is 
the absence of these substances which in part explains the 
failure of some fats to promote growth. The necessary amount 
of natural fat required per day is not known — the minimum 
has been estimated at from 25 to 50 grams of fat per day. 

Fat is a much more concentrated food than carbohydrate 
or protein in the sense that it yields, because of its lower state 
of oxidation, a greater amount of energy for a given weight: 

Calories Calories 

per gram. per pound. 

Fat 9.0 4082 

Carbohydrate 4.0 18 14 



198 FAT-RICH FOODS 

It is therefore the most economical means available to the 
body for storing energy against future need. But not all the 
fat of the body comes from fat; it may be formed from carbo- 
hydrate (glucose). Protein yields complexes which may be 
built up into fat. 

Fat is present in the human diet in two forms: (a) that asso- 
ciated with the food as it occurs naturally and (b) that which 
has been extracted from the medium in which it was deposited 
— flesh, milk, fruits — and which is ingested as such or added 
to food in the process of preparation. Prepared fats are sim- 
ilar to the unextracted fats, for the processes of manufacture 
are essentially physical ones: the fatty substance is separated 
from its surrounding medium by means of pressing, churning, 
or heat or a combination of these; very little chemical change 
takes place except perhaps in some forms of rendering or heat- 
ing in which there is a partial hydrolysis and slight oxidation 
of the original fats. We shall therefore confine our discus- 
sion largely to the manufactured fats and oils, indicating 
occasionally the relative fat content of certain particularly 
fatty natural foods when discussing the particular prepared 
fat which it would yield. 

Two types of fat-rich foods are obtained from milk: cream, 
in which the finely emulsified fat is concentrated by gravity 
or centrifugal force and which contains a small proportion of 
all the constituents of milk, and butter, in which the fat drop- 
lets are made to coalesce. Butter contains very little of the 
milk constituents other than the fat. 

CREAM. 

Cream is obtained from milk in two ways, both depending 
upon the diflPerence in specific gravity between the fat and the 
other constituents. Formerly milk was placed in a cool place 
for six to eight hours and the fat or cream permitted to rise 
to the top; it was then removed or ''skimmed off." The 
separation of the cream from the milk is hastened by the use 
of a centrifuge or separator which throws the heavier portions 
of the milk, water, protein, insoluble salts and cells to the 
periphery from which it is removed while the lighter fat is 
drawn off from the center. With the separator varying 
concentrations of butter fat can be obtained in the cream. 

BUTTER. 

Butter is obtained from cream by the process of churning, 
i. e., by mechanical agitation the natural emulsion of milk is 



BUTTER 199 

destroyed and the fat droplets made to coalesce. This pro- 
cess is facilitated by the slight changes produced in the cream 
as the result of fermentation or souring. The crude butter 
collected in the process of churning is separated from the rest 
of the cream — the butter milk — washed and worked into the 
final product which we know as butter. The process of work- 
ing removes most of the particles of curd remaining and the 
soluble constituents of milk. This gives pure, uncolored 
sweet butter. Salt is usually added to sweet butter to give 
it a flavor; it also acts as a preservative. The amount added 
varies according to the market for which it is intended — from 
o to 4 per cent. In salting a very good grade of sodium chlo- 
ride is used. Salted butter is then worked to distribute the 
salt, to remove the excess of water, to press the particles of 
fat together into a compact mass, and to give it the texture 
characteristic of the butter of commerce. 

The color of butter will vary according to the nature of the 
diet of the cow, for the coloring matter of the body fat and 
milk has been shown to be derived from the coloring matter 
of plants. Butter made from the milk of cows receiving cer- 
tain green foods is particularly rich in the yellow color com- 
monly associated with butter; thus butter made in the spring 
usually has a deeper yellow color than that made in the win- 
ter. To ensure a butter of uniform color throughout the year 
dairymen resort to the use of coloring matter. 

The presence of bacteria in butter is a matter of fully as 
great importance as their presence in milk. The processes of 
butter-making tend to increase the number of bacteria : centrif- 
ugalization so generally employed for the separation of cream 
from milk tends to leave the bacteria in the cream and the 
conglomeration of the particles of fat in the process of churn- 
ing results in a concentration of bacteria in the butter. The 
result is that butter often contains many more bacteria than 
the cream from which it is prepared. The souring of cream 
before its use in butter-making results in an accumulation of 
lactic-acid-producing bacteria with an accompanying decrease 
in the rate of growth of certain other types. The Bacillus 
tuberculosis has been found in butter prepared from milk 
containing this organism; cold storage does not result in the 
death of the bacillus. 

The following table gives the composition of American 
creamery butter: 

Per cent. 

Fat 82.41 

Water 13 90 

Lard 2.51 

Curd 1. 18 



200 FAT-RICH FOODS 

Variation from these figures will occur, depending upon the 
process of manufacture. Dividing the sample of butter into 
classes according to the fat content, the following general 
variations were observed in the case of the data given above: 
butter fat 5.0 per cent., water 2.9 per cent., salt 1.74 per 
cent., and curd 0.39 per cent. 

Butter fat is a mixture of the glycerides of various fatty 
acids with small amounts of lipoids — lecithin and choles- 
terol — and coloring matter. The relative proportions of these 
individual fats, or as they are usually expressed in analysis, 
*' fatty acids," varies with the food, particularly with the fat 
content of the food, the individuality of the cow and stage of 
lactation. The taste and odor of butter is influenced by the 
food given the cow; garlic, for instance, gives to milk and 
butter a decided odor characteristic of the plant. 

The following table gives the distribution of the more im- 
portant fatty acids found in a particular sample of butter:^ 

Percentage of 
Acid. triglycerides. 

Dioxystearic i . 04 

Oleic 33-94 

Stearic 1.91 

Palmitic 40.51 

Myristic 10.44 

Laurie 2.73 

Capric 0.34 

Caprylic 0.53 

Caproic 2.32 

Butyric 6.23 

Butter fat is practically completely absorbed. The average 
caloric value of butter, based upon an 85 per cent, fat con- 
tent is approximately 3500 Calories per pound or j.j Calories 
per gram. 

Renovated Butter and Butter Substitutes. — When butter 
which has become rancid is treated to restore its sweetness the 
product is designated as '^processed or renovated" butter. The 
rancid butter is melted, the curd and brine drawn ofF, the fat 
separated and aerated and then rechurned with milk or cream 
to restore the texture and flavor. Such butter is in many 
respects as satisfactory as the average grade of butter; it is 
not equal in quality to the better grades of butter. 

Oleomargarine. — A fat product prepared from various animal 
and vegetable fats and oils which resemble butter in its con- 
sistency is sold under various names, of which oleomargarine 
or margarine are the most common. Its manufacture is 
restricted by the government; a tax is levied against it, a 

' Browne: Jour. Amer. Chem. Soc, 1899, xxi, 807. 



LARD 201 

fourth cent per pound for the uncolored product and ten cents 
per pound for oleomargarine artificially colored to resemble 
butter. Yet oleomargarine is a satisfactory substitute for 
butter; it is often more desirable than some good grades of 
butter. One objection to oleomargarine is that it is many 
times sold as butter with the intent to deceive. Containing 
as it does a higher percentage of stearin, we might expect to 
find oleomargarine less readily absorbed than butter; experi- 
ence has shown, however, that the losses in digestion are nearly 
the same for the two products. Butter is, however, in many 
ways a finer product and more palatable. It is much richer 
in the accessory substances or vitamines than oleomargarine 
and is from this point of view a much more desirable food. 

The materials used in the manufacture of oleomargarine are 
chiefly neutral lard, "oleo oil," and cotton seed oil. Neutral 
lard is prepared from the fresh "leaf lard" of the hog. This is 
ground up, worked with water, and rendered at a temperature 
of 40° to 50° C. Only a portion of the lard is removed from 
the fat. The product obtained is almost neutral in reaction 
and practically free from taste or odor. Oleo oil is prepared by 
a somewhat similar process. Fat from the abdominal cavity 
of beef or caul fat is thoroughly worked in water, chilled, 
the hardened fat ground up and finally rendered at a low tem- 
perature. The Hquid fat obtained by this process is permitted 
to cool, when stearin and palmitin partially crystallize out. 
The fluid portion is pressed out of the semisolid mass, run 
into cold water and allowed to soKdify. This product is desig- 
nated as "oleo" or "oleo oil." The cotton seed oil used is 
especially prepared for the purpose. Cocoanut fat and peanut 
oil are also used. In the final stage of preparation the fats 
and oils are mixed in the desired proportion; the quantities of 
the various constituents used depends upon the market for 
which the oleomargarine is intended. For warm climates 
more of the oleo oil and lard are used than for cold climates. 
The properly mixed fats are then churned with milk or cream, 
or with an emulsion of milk and butter to give the flavor of 
butter to the product. This yields a coarse emulsion which, 
upon cooling, is washed, salted, and worked into the final 
product. The following is the composition of oleomargarine, 
given by Koenig, in per cent.: Water, 9.07; fat, 87.59; nitrog- 
enous extractives and lactose, 0.99; ash, 2.35; sodium 
chloride, 2.15. 

LARD. 

Lard is the rendered fat of the hog. The fat is extracted 
by means of heat which liquefies it and gradually frees it from 



202 FAT-RICH FOODS 

the connective tissues. Lards are designated according to the 
portion of the animal from which they are prepared and the 
mode of rendering. "Neutral" and ''leaf lard are obtained 
from the fat surrounding the kidneys. The preparation of the 
former has already been indicated (p. 201). ''Leaf lard" is 
obtained by heating the leaf fat or the residue from neutral 
lard to a higher temperature with steam. Kettle-rendered 
lard is made from leaf and back fat by heating in open jacketed 
kettles. Steam lard is made from the remaining portions of 
the hog not used for direct consumption by the direct applica- 
tion of steam. 

Various substitutes for lard are prepared and sold under 
trade names. They are ordinarily mixtures of cotton seed oil 
and beef fat or specially treated cotton seed oil. 

COTTON SEED OIL. 

Cotton seed oil is used extensively as a substitute for olive 
oil or in the preparation of substitutes for animal fats. In the 
preparation of cotton seed oil the cotton seeds are cleaned and 
ground, the meal heated under pressure to 210° to 215° F. and 
the oil expressed with hydraulic presses while still warm and 
the crude oil refined. The best grades of cotton seed oil are 
practically free from any characteristic flavor and are suit- 
able substitutes for olive oil. As with the butter substitute, 
oleomargarine, the real objection to its use is the economic 
one, that it is often sold as olive oil. However, it lacks the 
characteristic natural flavor of olive oil. 

By a process of chilling and pressing the higher melting- 
point fats of cotton seed oil are partially separated from the 
more liquid ones. The former are used as substitutes for lard 
while the latter become a satisfactory oil for cold climates. 

Cotton seed oil is used extensively in the preparation of lard 
substitutes in which the fatty acids of the liquid unsaturated 
fats are transformed, reduced into their corresponding satu- 
rated compounds, which are solid at the ordinary tempera- 
tures. These transformations are brought about by heating 
with hydrogen in the presence of finely divided nickel. The 
nickel is added as a catalyst to hasten the reaction between 
hydrogen and the fatty acid. Small quantities of nickel remain 
in the final product and there is a possibility that they may be 
detrimental to health. This point has not as yet been determined. 
Such prepared products are as well utilized as lard and other 
fats and might well be substituted for them when cheaper 
were it not for the nickel present. 



COD-LIVER OIL 203 

OLIVE OIL. 

Olive oil is prepared by pressing the flesh of the ripe olive. 
The selection of the olive and the mode of preparation deter- 
mine in general the grade of oil. The highest grade of oil, 
virgin oil, is from selected hand-picked olives. The product is 
obtained by slight pressure of cold oUves. Subsequent pressure 
of the mass, first cold and then later heated with water, gives 
the various more or less inferior grades of oil. In some pro- 
cesses the olives are macerated and crushed before being sub- 
jected to pressure. The various oils obtained are subjected 
to a refining process in which foreign particles are removed 
by filtration and by gravity in settling tanks. Of the fatty acids 
present in fats of olive oil palmitic and oleic are the most 
important: there is Uttle, if any, stearic. Other fatty acids are 
present but only in small quantities. Practically all of these 
fatty acids occur as neutral fat or glycerides; the small per- 
centage which exists as free fatty acids varies with the ripe- 
ness of the fruit and the mode of preparation; most of the 
high grades of oil contain less than 3 per cent. Olive oil is 
eaten principally in salads; it is used to some extent in cook- 
ing. Other vegetable oils are used for food, such as peanut 
oil, sesame oil, cocoanut oil, etc. Vegetable oils have been 
found to be fully as digestible as animal fats. 

COD-LIVER OIL. 

Cod-liver oil is prepared by means of pressure from the raw 
fresh livers of codfish. It has been used extensively because 
it is apparently assimilated under conditions in which other 
fat foods are not effective. It contains a number of low melt- 
ing-point saturated fats in addition to olein, which is present 
to the extent of approximately 70 per cent., cholesterol, a 
small amount of iodine, and a number of basic substances are 
also present. The presence in cod-liver oil of specific sub- 
stances necessary for growth and maintenance, such as are 
found in butter and egg yolk, may be one of the reasons for its 
successful use in therapeutics. Cod-liver oil is sometimes 
adulterated by the admixture of other fish oils which results 
in an inferior product. Preparations are also sold which pur- 
port to have all of the therapeutic properties of cod-liver oil 
without the peculiar oily taste which is repugnant to some 
persons. Those preparations from which the fat has been 
entirely or largely removed are practically useless as substi- 
tutes for cod-liver oil since the therapeutic value rests as 
much in the readily assimilable oils as in any other factor. 



CHAPTER XIV. 

FOODS VALUABLE FOR THEIR SALTS, WATER, 
AND BULK. 

In addition to those foods which furnish primarily protein, 
carbohydrate, or fat is a group of foods which, while supply- 
ing these food-stuffs to a certain extent, are not sufficiently 
rich in them to be valuable sources of such material. They 
form, however, an important part of the diet because they 
are valuable sources of inorganic salts (particularly the salts 
of organic acids), of water, and of certain "accessory" food- 
stuffs essential for a satisfactory diet. They are compara- 
tively indigestible. It is the indigestible residue which serves 
to give bulk to the intestinal contents and thus promotes 
peristalsis. Some of these foods contain a certain amount of 
soluble material which in itself stimulates peristalsis — laxa- 
tives. These water-rich, indigestible foods are then a means 
of adding salts, accessory substances and bulk to the diet 
without markedly increasing the energy or protein portion of 
the regimen. In addition to these purely material advantages 
they are in most cases appetizing and are in this way valuable as 
aides to digestion. To this class of foods belong the succulent 
plant foods — the vegetables and fruits. A clear-cut classifi- 
cation is difficult in a few cases. To classify dried legumes as 
protein foods, and fresh and canned varieties of the same food 
as valuable chiefly for their salts and their value as appetizers 
may appear illogical. A consideration of their usual place in 
the diet, however, makes this the most desirable classification. 
Our discussion will confine itself, therefore, unless otherwise 
stated, to the succulent fruits and vegetables. 

Fruits and vegetables are composed largely of water; cellu- 
lose, the chief structural material; starches; sugars; organic 
acids; gums; mineral matter; protein, and a small amount of 
fat. So far as nutritive value is concerned, the quantities of 
the food-stuffs present are so small as to be practically negli- 
gible. The small amount of protein is poorly absorbed; carbo- 
hydrate, exclusive of cellulose, and fat are almost completely 
digested, but the small quantity ingested is very seldom of 
practical importance. This is particularly true of the fat. 

The indigestibility of fruits and vegetables as a whole is due 



FOODS VALUABLE FOR SALTS AND WATER 



205 



to the cellulose content. Cooking will increase the digestibility 
of this carbohydrate to a certain extent, particularly in the 
case of raw fruit and the starchy vegetables, for it softens 
the cellulose structures and ruptures the starch grains. The 
accompanying table gives the composition of some of the 
more important fruits and vegetables. 

Chemical Composition of Typical Fruits. 

FRESH. 



Fruits. 


i 




c 

a; 


1 • 
^8 


11 

1' 


*; 

s 


5? a 


a 

■3 













6 


< 




is 




Apples 


. 84.6 


0.4 


0.5 


14.2 


1.2 


0.3 


285 


159 


Bananas . 


• 75 


3 


1-3 


0.6 


22.0 


1.0 


0.8 


447 


lOI 


Blackberries . 


. 86 


3 


1-3 


I.O 


10.9 


2.5 


0-5 


262 


173 


Cherries . 


. 80 


9 


I.O 


0.8 


16.7 


0.2 . 


0.6 


354 


128 


Grapes 


• 77 


4 


1-3 


1.6 


19.2 


4-3 


0.5 


437 


104 


Huckleberries 


. 81 


9 


0.6 


0.6 


16.6 




0-3 


336 




Lemons . 


• 89 


3 


I.O 


0.7 


8.5 


I.I 


05 


201 


226 


Muskmelons . 


• 89 


5 


0.6 




9-3 


2.1 


0.6 


180 


252 


Oranges . 


. 86 


9 


0.8 


0.2 


II. 6 




05 . 


233 


195 


Peaches 


• 89 


4 


0.7 


0.1 


9.4 


3-6 


0.4 


188 


242 


Strawberries . 


• 90 


4 


1.0 


0.6 . 


7-4 


1-4 


0.6 


177 


256 






DRIED. 












Apples 


. 28.1 


1.6 


2.2 


66.1 




2.0 


1318 


34 


Dates . . . 


• 154 


2.1 


2.8 


78.4 




13 


1575 


29 


Figs . . . 


. 18.8 


4-3 


0-3 


74.2 




2.4 


1437 




Prunes 


■ 22.3 


2.1 




73-3 




2-3 


1368 


33 


Raisins 


14.6 


2.6 


3-3 


76.1 




3-4 


1562 


29 


Ch 


EMicAL Composition of Typical 


Vegetables. 










>n 






h . 




^•6 


bO 

.s 




-jf 


(M 






^a 




Is fl 


"^ « 


Vegetables. 


a 


<6 
B q3 




-2 


3S 




"1 

— SR 


1 




"eS 


a 


Is 


^0- 


2° 


4 


§.2 






^ 


CU 


f2 








< 


^ 





Asparagus 


• 940 


1.8 


0.2 


3-3 


0.8 


0.7 


lOI 


450 


Beans, fresh: 


















Lima 


• 68.5 


71 


0.7 


22.0 


17 


1-7 


557 


82 


String . . 


■ 89 


2 


2.3 


0-3 


7-4 




0.8 


189 


241 


Cabbage . 


• 91 


5 


1.6 


0.3 


5-6 


I.I 


1.0 


143 


317 


Carrots 


. 88 


2 


I.I 


0.4 


9-3 


I.I 


I.O 


205 


221 


Celery . . 


• 94 


5 


I . I 


0.1 


3-3 


. . 


1.0 


84 


540 


Lettuce 


• 94 


7 


1.2 


03 


2.9 


0.7 


0.9 


87 


524 


Potatoes: 




















White . . 


• 78 


3 


2.2 


0.1 


18.4 


0.4 


I.O 


378 


120 


Sweet . 


• 69 





1.8 


0.7 


27.4 


1-3 


I.I 


558 


81 


Pumpkins 


• 93 


I 


1 .0 


0.1 


5-2 


1.2 


0.6 


117 


389 


Spinach 


92 


3 


2. 1 


0.3 


3-2 


0.9 


2. 1 


109 


418 


Tomatoes 


• • 94 


3 


0.9 


0.4 


3-9 


0.6 


0.5 


104 


439 



206 



FOODS VALUABLE FOR SALTS AND WATER 



Fresh vegetables and fruits have long been known for their 
antiscorbutic properties. These have been ascribed to the pre- 
dominance of the basic elements in the ash. While this may 
be a factor, recent work has shown the presence of the acces- 
sory food-stufFs, vitamines, which may be of much more 
importance. 

The constituents of vegetables and fruits which make them 
so desirable as foods are the salts and in fruits, the acids or acid 
salts, soluble sugars, and the essential oils, esters and ethers 
which give the pleasant taste. Cellulose is important for its 
laxative effect. The pleasing appearance of fresh and cooked 
vegetables and fruits has some esthetic value. Most fruits 
and many vegetables are palatable even in the raw state, in 
which form it is the crispness of the pulp or leaf which is 
particularly attractive. The delicate coloring matter which 
these foods contain is not only attractive to the eye but serves 
to stimulate the appetite. When cooked with sugar, as pre- 
serves or jellies, these coloring matters and flavors are the 
means of increasing the appetite not only for the conserve 
itself but for insipid foods, chiefly carbohydrates, to which 
they are added. In this way they are valuable in the diet of 
the sick room. 

Vegetable foods are comparatively tasteless. To make 
them palatable it is necessary to add fats, usually in the form 
of oil or butter, and condiments, particularly acids, e. g.y vinegar. 
The addition of salt to vegetables is also necessary. 

The importance of vegetables and fruits as sources of salts 
is indicated by the following table which gives the percentage 
of individual ash constituents of typical vegetables and fruits: 

Composition of the Ash of Typical Fruits. ^ 









FRESH 












Fruits. CaO. 


MgO. 


K2O. NazO. P2O5. 


CI. 


s. 


Fe. 


Apples . . 


014 


.014 


•15 


.02 


03 


.004 


.005 


.0003 


Bananas 


01 


.04 


•50 


.02 


055 


.20 


.013 


.0006 


Blackberries . 


08 


•035 


.20 




08 




.01 




Cherries 


03 


.027 


.26 


•03 


07 


.01 


.01 


.0005 


Grapes 


024 


.014 


•25 


•03 


12 


.01 


.024 


.0013 


Huckleberries . 


035 


.025 






07 


.02 


.013 


.0011 


Lemons 


05 


.01 


.21 


.01 


02 


.01 


.012 


.0006 


Muskmelons 


024 


.02 


.283 


.082 


035 


.041 


.014 


.0003 


Oranges 


06 


.02 


.22 


.01 


05 


.01 


.013 


.0003 


Peaches 


01 


.02 


•25 


.02 


047 


.01 


.01 


.0003 


Strawberries 


05 


.03 


.18 

DRIED 


.07 


064 


.01 




.0009 


Dates . . . 


10 


•13 






12 


• 32 


.066 


.003 


Figs . . . 


299 


•145 


1.48 


.064 


332 


.056 


.056 


.0032 


Prunes . 


06 


.08 


1.2 


.1 


25 


.01 


■03 


.0029 


Raisins . 


08 


•15 


I .0 


•19 


29 


.07 


.06 


.005 



Sherman: Food Products, 1914, p. 347. 



COMPOSITION 



207 



Composition of the Ash of Typical Vegetables. 



Vegetables. 


CaO. 


MgO. K2O. Na20. P2O5. 


Cl. 


s. 


Fe. 


Asparagus . 


. .04 


.02 


20 


01 


09 


04 


.04 


.001 


Beans: 


















Lima 


. .04 


. II 


7 


12 


27 


009 


.06 


.0025 


String 


• 075 


•043 


28 


03 


12 


018 


.04 


.0016 


Cabbage 


. .068 


.026 


45 


05 


09 


03 


.07 


.0011 


Carrots 


• 077 


•034 


35 


13 


10 


036 


.022 


.0008 


Celery . . 


.10 


.04 


37 


II 


10 


17 


.025 


.0005 


Lettuce 


. .05 


.01 


42 


04 


09 


06 


.014 


.001 


Potatoes: 


















White . 


.016 


.036 


53 


025 


14 


03 


•03 


.0013 


Sweet 


. .025 


.02 


47 


06 


09 


12 


.02 


.0005 


Pumpkins . 


■ 03 


•015 


08 


08 


II 


01 


.02 




Spinach 


. .09 


.08 


94 


20 


13 


02 


.041 


.0032 


Tomatoes . 


.02 


.017 


35 


01 


059 


03 


.02 


.0004 



Green vegetables and fruits are an important source of iron. 
Investigations have shown that combined iron, such as occurs 
in nature is in a readily assimilable form, probably in the most 
desirable state. The iron of meat is chiefly in the form of 
hemoglobin, which is comparatively indigestible. The iron 
compounds of vegetables and fruits are, however, quite readily 
digested and absorbed. It is the availabihty of the iron which 
makes plant foods desirable in the diet for the iron they 
contain. 

The tables indicate only the relative amounts of the various 
elements, or their oxides, present in fruits and Vegetables. If 
we consider them with regard to the form in which these 
elements exist we find the basic elements combined with both 
inorganic and organic radicles. The organic acids exist in 
many cases as the acid salts, chiefly the acid potassium salts. 
As the organic acids occur in the fruit or vegetable they exhibit 
in some cases a considerable degree of acidity, as is the case 
of lemons or apples. After absorption in the body the organic 
acid is oxidized and the base, associated with the acid, com- 
bines with carbonic acid to form the carbonate which func- 
tions as a potential base. An examination of the ash of fruits 
and vegetables shows it to contain an excess of base- over the 
acid-forming elements. In our discussion of inorganic salts 
it was noted that animal food is, with the exception of milk, 
potentially acid-yielding. Vegetables are then important in 
the dietary, for their ability to neutralize the acids produced 
in metabolism. In the case of fruits and vegetables it is the 
small amount of nutritive material associated with the salts 
which makes it possible to balance the diet with regard to its 
acid- and alkali-forming properties, so as to aid in the main- 
tenance of the neutrality of the blood. For the same reason, 
vegetables are important when it is desired to reduce the 
potential acidity of the blood and urine. An excess of base- 



208 FOODS VALUABLE FOR SALTS AND WATER 

forming elements is not as objectionable as an excess of acid- 
forming elements because of the ever-present excess of carbon 
dioxide to form bicarbonate with the base. The natural ten- 
dency to ingest plant food with meat in a mixed diet has had, 
therefore, a scientific foundation. The greater solubility of 
uric acid in an alkaline urine, resulting from the ingestion of 
an excess of basic material, than in a neutral or acid urine is 
also an advantage. 

The sugars of fruits and vegetables are chiefly sucrose (cane- 
sugar), dextrose, and levulose. Some fruits, such as the grape, 
often contain a high proportion of sugar. 

The more important plant acids are citric (lemon), malic 
(apple), tartaric (grape), and in some oxaHc acid. The acids 
occur in varying proportions in the diflFerent fruits and vege- 
tables. The fruits designated in parentheses above are repre- 
sentative of the class of fruit in which the particular acid 
predominates; other acids are also present. The relative pro- 
portion of starch, sugar and acid in fruits varies during the 
process of ripening. The following table gives the variation 
in the composition of an apple at various stages of its growth. 

Composition of Baldwin Apple at Different Periods in Its Growth^ 

Per cent. 



Condition. 


Water. 


Solids. 


Invert 
sugar. 


Sucose. 


Total 
sugar. 


Starch. 


Free 
malic 
acid. 


Ash. 


Very green 
Green . 


• 81.5 

■ 79-8 


18.5 
20.2 


6.4 
6.5 


1.6 
4.1 


8.0 
10.5 


41 

3-7 


1.2 


0.27 


Ripe . . 
Overripe . 


. 80.4 
• 80.3 


19.6 
19.7 


7-7 
8.8 


6.8 
5-3 


14. I 


0.17 


0.65 
0.48 


0.27 
0.28 



Green fruit, in general, contains considerable starch. As the 
fruit ripens there is a gradual reduction in the quantities of 
the starch and acids and an increase of sugar. Pectin, the 
carbohydrate which forms the basis of jellies, gradually 
decreases as the fruit ripens. 

Cooking of Vegetables and Fruits. — Vegetables and fruits are 
cooked to soften the cellulose structure, rupture the starch 
grains, improve the texture and flavor, and thereby increase 
digestibility and palatability. Many fruits and vegetables 
which are also eaten in the raw form are cooked to add variety 
to the diet and for purposes of preservation. Heat converts 
the water in the cells into steam, the expansion of which rup- 
tures the cells, freeing the enclosed starch; an exaggerated 
example of the expansive action of steam is seen in the pop- 
ping of corn, in which expansion takes place suddenly through- 

' Browne: Pcnn, Dept. Agr., Bull. 58. 



COOKING OF VEGETABLES AND FRUITS 



209 



out the whole mass of starch cells when the internal pressure 
is sufficient to rupture the tough outer layer of the kernel. 
During the process of cooking hydrolytic changes occur: the 
starch and cellulose are partially hydrated, take up water, 
and are transformed into simpler products — glucose and 
sugars; protein is coagulated; the mineral salts are only slightly 
affected. 

Since inorganic salts are, from a dietetic point of view, one 
of the important food factors in fruit and vegetables, it is 
desirable, then, to conserve them as much as possible. In 
boiling, the method usually employed for cooking vegetables, 
a large proportion of the salts and also protein may be lost; 
by direct removal before cooking, as in peeling; by extraction 
in the water used in washing and soaking, or discarded 
with the water poured off at the end of the cooking process. 
Methods which will avoid these losses should be used. Baking 
or steaming, with the least removal of outer coverings, is the 
most desirable. Some vegetables, such as spinach and chard, 
which are cooked by steaming in the water contained in 
them, are found to lose a large proportion of their salts when 
the liquor is poured off before they are served. 



Losses in Cooking Vegetables (Percentage of Fresh Edible 
Portion).! 



Kind of vegetable. 


Solids. 


Ash. 


P2O6. 


CaO. 


MgO. 


Spinach : 












Boiled 


. 31-59 


5165 


52.33 


6.89? 


60.38 


Steamed .... 


. 0.18 


9-34 


523 


8.69 


7-85 


Cabbage : 












Boiled 


. 32.86 


42.62 


33-93 


27.66 


26.71 


Steamed .... 


2.54 


11.47 


1.79 


9-31 


4 23 


Carrots: 












Cut up and boiled 


. 10.05 


11.48 


22.88 


10.88 


19.19 


Boiled whole . 


6.28 


7.38 


17.97 


8.77 


19.19 



Fruits and vegetables may be kept at ordinary temperatures 
for a considerable length of time before they begin to decay, 
wilt, or dry up. With proper refrigeration many of them can 
be kept for a comparatively long time. Such a method of 
preservation is becoming more prevalent, and some vegetables 
and fruits may be had throughout the year. Apples in par- 
ticular are commonly preserved in cold storage. 

The process of canning fruit and vegetables has long been 
used by the housewife to preserve them for use when out of 
season. Canned foods can now be purchased in the stores in 
great variety, tomatoes, corn, and peas being supplied in the 
greatest quantity. Since canned fruits and vegetables retain 



Berry: Jour. Home Economics, 19 12, iv. 



14 



210 FOODS VALUABLE FOR SALTS AND WATER 

most of the properties of the freshly cooked food they are 
excellent sources of this type of food in the winter when green 
vegetables are generally "out of season." In canning, vege- 
tables and, to a certain extent, fruit are heated only enough 
to sterilize them. This is done after the can is sealed. Sugar 
is often added to fruit to aid in their preservation and increase 
the flavor. The juice of fruits is also sterilized and kept for 
use as beverages or mixed with sugar and made into jellies. 
It is the pectin of fruit which gelatinizes and forms the basis 
of jellies. 

FOOD ADJUNCTS. 

Food which is entirely satisfactory, in its quantitative com- 
position, with regard to proteins, fat, carbohydrate, salts, and 
even the accessory substances or vitamines, may be in such a 
form that it is not relished; we have no desire to eat it. This 
distaste may be due to the appearance or taste of the particular 
food, or to a lack of interest in food in general. Such condi- 
tions are not confined to man alone. These factors do not 
affect the ultimate absorption of food so much as is sometimes 
thought, for food-stuffs which are ingested with much effort 
have been found to be just as thoroughly digested as those 
which were appetizing. The extent of variation in the diet 
is a matter largely of personal taste. Some people relish the 
same diet day after day, while others require frequent changes. 
Animals fed artificial diets of similar composition from day 
to day often refuse to eat. If to the same diet small amounts 
of flavoring substances, having no nutritive value, be added 
and the flavor changed from time to time, it will be eaten 
readily during long periods of time. There are also experi- 
ments on the flow of gastric juice which show that when 
there is desire for food, the mere sight of food results in a flow 
of highly acid and strongly active gastric juice which starts 
the process of gastric digestion, the products of which are 
capable of causing a continued secretion. Certain food con- 
stituents, such as the extractives of meat and some condi- 
ments, are capable of stimulating such a flow of gastric juice, 
and this in turn affects the secretion of the other digestive 
juices. The garnishing of food when served likewise has 
through the increased attractiveness of the dish a beneficial 
effect upon the digestion of food. There is a fundamental 
reason, therefore, for the use of condiments and for different 
methods of preparing food. 

Spices. — Spices are used almost exclusively for their flavor. 
Such spices as allspice, cloves, cinnamon, ginger, caraway, 



BEVERAGES 211 

etc., are used chiefly in cooking. The peppers (black and 
white), paprika, mustard, and horse-radish are often added 
to food after it has been prepared. 

Flavoring Extracts. — Many alcohoUc extracts of various 
plants of which vanilla, lemon, orange, peppermint, spear- 
mint, and wintergreen are the most common, are used to add 
an agreeable flavor or taste to foods. 

Meat Extracts.— Meat extracts are to be classed with the 
food adjuncts (see p. 152). 

Vinegar. — Vinegar is the product of the alcoholic and acetic 
acid fermentation of fruit juices; its distinguishing constituent 
is acetic acid. It may also be prepared from the products of 
alcohoHc fermentation of grain or is compounded from acetic 
acid and substances to give a flavor and color which will 
simulate the natural vinegars. Vinegar is used with more or 
less insipid foods to intensify the flavor, and to soften food 
somewhat; for colloidal material tends to swell in acid 
solutions. 

Sugar and Salt (Sodium Chloride). — Sugar and salt may both 
be classified differently but may, for convenience, be included 
here as condiments, for they are used to add flavor and stimulate 
the appetite. 

Sugar Substitutes. — Saccharine, dulcin, granatose and saxin, 
benzene derivatives, are sometimes used in place of sugar 
to sweeten food. These products are used particularly to 
sweeten the food of diabetics and of the obese to increase 
its palatability without increasing the carbohydrate content. 
When taken in sufl&cient quantity these substitutes for sugar 
are harmful. It is the contention of manufacturers that 
small quantities are not deleterious to the health. While this 
may be true during short periods of time, it is doubtful whether 
their continued ingestion may not cause serious disturbances 
in the body. Their use in diabetes is defensible on the basis 
that the harmful eff'ects are overweighed by the possibiUty of 
reducing the carbohydrate content of the food. 



BEVERAGES. 

Many foods are ingested in a liquid or semiliquid form. 
There are, however, liquids which possessing a certain amount 
of food value, are taken for their stimulating effects upon 
the nervous and digestive systems. The pleasurable condi- 
tions under which they are ordinarily ingested should not be 
neglected in considering the effect of these beverages. 

Those beverages most commonly taken with food and most 



212 FOODS VALUABLE FOR SALTS AND WATER 

properly considered a part of the diet are tea, coffee, cocoa, choco- 
late, and the malted and spirituous (and carbonated) liquors. 

Tea. — Tea is prepared from the leaves and leaf buds of various 
varieties of hardy shrubs, Thea. Two general types of tea 
are used, green and black. This classification refers particu- 
larly to the general method of preparation. Green tea is pre- 
pared by steaming the withered leaves and then drying them 
in the sun or artificially, thus retaining the green color. Black 
tea has undergone a fermentation (or oxidation) process which 
darkens the color of the leaves and reduces the quantity 
of tannin. Numerous varieties of both kinds of tea may 
result from the selection of leaves from different parts of the 
shrub or twig or from the country or locality from which they 
are obtained. 

The active constituent of tea is theine or cafFein, but cer- 
tain volatile oils and tannin contribute to the aroma and 
taste of the prepared beverage. In the preparation of the 
beverage it is the relative proportion of these three con- 
stituents to which most attention is given. The end com- 
monly believed to be desirable is the extraction of the maxi- 
mum amount of caffein and volatile oils, with the minimum 
quantity of tannin. 

From a study of the nature of the products extracted from 
tea leaves the Lancet has come to the conclusion that it is 
the relative proportions of cafFein and tannin extracted which 
determine the quality of tea. They show that when caffein 
and tannin are present in the proportion of one part of caffein 
to three parts of tannin they may be precipitated completely 
by acidification in the form of cafFein tannate. Caffein tannate 
has neither the astringent taste of tannin nor the bitter taste of 
cafFein, and it is precipitated by acids. It has been suggested 
that the cafFein of tea, unlike the cafFein complex of cofFee, is 
precipitated in the stomach and is not absorbed until it reaches 
the alkaline intestine. A comparison of the valuation of tea 
by tea-tasters and the proportion of cafFein to tannin in the 
tea shows that the infusion of those teas classed as "good" con- 
tain these two substances in the proportion in which they 
exist in cafFein tannate, and that inferior teas yield an excess 
either of cafFein or of tannin in the infusion, usually the 
former. 

The following table shows the extractives from teas of three 
different types and the relative proportion of caffein and tan- 
nin contained. It will be seen that the high-priced teas con- 
tain a greater proportion of tannin and cafFein (cafFein 
tannate). 



BEVERAGES 



213 



Tea Infusions (5 Grams of Tea to 400 c.c. Boiling Water). 







Tannin 


Caffein 














Caffein 


com- 


com- 






Caffein 


Tannin 






tannate. 


bined 


bined 






not 


not 






Deter- 


with 


with 


Total 


Total 


com- 


com- 


Price 


Tea. 


mined. 


caffein. 


tannin. 


tannin. 


caffein. 


bined. 


bined. 


cents 


India 


• 8.54 


6.41 


2.13 


6.80 


2.56 


0.43 


0.39 


15 




13-36 


10.02 


3-34 


10.92 


432 


0.98 


0.90 


46 


Ceylon 


8.88 


6.66 


2.22 


6.30 


2.80 


0.58 




17 




12. 00 


9.00 


3.00 


8.40 


3.60 


0.60 




33 


China 


• 5.36 


4.02 


1-34 


3.02 


1.92 


0.58 




13 




6 .48 


4.86 


1.62 


4.60 


2.80 


I. 18 




35 



The chemical composition of the water used in making tea 
may affect the composition of the infusion, for, should the 
water be rich in calcium, the calcium will tend to precipitate 
the tannin and leave an excess of caffein. The period of extrac- 
tion affects the composition of the infusion; continued extrac- 
tion of good tea results for a time in a proportionate increase 
in both caffein and tannin so that the balance is but Httle 
disturbed; inferior teas, on the other hand, yield an excess of 
either caffein or tannin. Prolonged boiling of tea tends to 
extract a greater proportion of tannin. The "Lancet believes 
that caffein and not tannin is the injurious constituent of tea, 
for tannin is rarely in excess of the ratio in which it exists in 
caffein tannate. Studies of the quantity of caffein and tannin 
present in tea steeped for varying lengths of time have shown 
that practically all of the caffein is extracted in the first three 
to five minutes. A longer period of extraction results in an 
increased proportion of tannic acid in the infusion. For 
those, then, who desire to obtain the maximum aroma and 
exhilarating effect of the caffein without the bitter, stringent 
tannin, tea should be extracted for a short period. 

The total quantity of caffein and tannin present in the 
average cup of tea after an infusion of five minutes varies with 
the kind of tea — it has been found to be roughly i grain 
(0.07 gram) of caffein and three or four times as much 
tannin. The effects of tea are discussed with those of coffee 
on p. 216. 

Coffee. — ^The beverage coffee is prepared from the roasted 
bean, of the Caffea arabacia. The coffee berry contains a bean 
composed of two elongate, hemispherical halves enclosed in a 
thin membranous sheath, which is surrounded by an outer 
layer of pulp. The berries are separated and roasted to preserve 
them, to render them brittle and readily ground, and to 
develop certain flavors and aroma. In the roasting process a 
large proportion of the sugar is carameHzed, and there are losses 
ot water and to a certain extent of caffein. Caffeol is the 
name given to a mixture of substances present in the roasted 



214 FOODS VALUABLE FOR SALTS AND WATM 

product which gives to coffee its characteristic flavor and 
aroma. The alkaloid of coffee is, as in tea, largely caffein. 

The caffein of coffee is combined in a different manner from 
that of tea; it is almost entirely extracted by cold water while 
that of tea is not. It appears to be combined with an acid 
designated as caffetannic acid related to tannin but exhibit- 
ing properties different from those of the tannic acid of tea. 
The caffein of coffee is soluble in both an acid and an alkahne 
medium, while that of tea is precipitated by acids. This fact 
may account for the greater stimulatory effect of coffee than 
of tea, for the caffein being in solution may be absorbed by 
the stomach, while that of tea must pass to the intestines for 
solution and absorption. 

The several kinds of coffee vary chiefly according to the 
country from which they are obtained. As with tea the 
advantage of the different kinds is to a considerable extent a 
matter of taste. 

The coffee bean contains roughly one-third the quantity of 
caffein present in dry tea. The greater quantity of coffee used 
gives approximately the same quantity of caffein in both 
prepared beverages. Coffee contains a greater amount of 
total extracted material. 

In the process of preparing coffee for its most pleasureable 
effects the caffein and the aroma are the two constituents 
which it is desirable to extract. It has been found that when 
2 ounces (60 grams) of coffee are used, a teacupful of coffee 
will contain approximately 1.7 grains (o.i gram) of caffein, a 
value which is slightly higher than that of tea; the smaller 
quantity of infusion taken when cream or milk are used will 
make this value sHghtly lower. The quantity of caffein and 
caffetannic acid extracted in the preparation of coffee varies 
considerably with the mode of preparation. Cold water 
extracts approximately the same weight of material from 
coffee as does hot water, but hot water extracts oils which 
improve the odor and taste of the beverage. 

Four general methods of preparing the beverage coffee are 
used: boiling, steeping, percolation, and filtration. 

Boiled coffee is prepared by heating medium-ground coffee 
placed in cold water to the boiling-point and maintaining it 
at that temperature for five minutes. This method gives the 
greatest proportion of extract, and one which is rich in caffein 
and caffetannic acid. 

Steeped coffee is similar to boiled coffee except that the 
infusion is poured off soon after the boiling-point is reached. 
This method yields the lowest caffein content. 

Percolation consists in passing warm water through finely 



BEVERAGES 215 

ground coffee in a specially constructed coffee pot. The tem- 
perature of the water which is forced over the coffee seldom 
reaches the boiling-point. A low total extract high in caffe- 
tannic acid and caffein is obtained. 

Filtered coffee is made from finely pulverized coffee which 
has been placed in a muslin bag and over which vigorously 
boiling water is poured. The product is lower in total extrac- 
tives and contains less caffetannic acid than boiled coffee. 
If the water be poured through more than once a darker liquid 
is obtained which has a less agreeable flavor because of the 
additional tannin and other objectionable substances. This 
method of preparing coffee is in many ways the most satis- 
factory.^ The cloth used should not be allowed to dry but 
should be kept in clear cold water. 

A comparison of the relative quantities of caffein and tannin 
extracted by the various methods is given below. 



Tannin and Caffein Extracted by Various Methods of Preparation 
(7 Tablespoonfuls (80 Grams) Coffee to 6 Cups (750 c.c.) Water). 

Method of preparation. 
Boiled 



Tannin 




Caffein, 


grains. 




grains. 


2.44 




2.5 

(0 . 5 medium ground 
\1.75 finely ground 


2 .40 




2.21-2. 


90 


2.75 


0.2 -0. 


25 


2.50 



Steeped 

Percolated 

Filtered 



Specially prepared coffees are sold for the use of those who 
cannot take coffee because of its caffein content, usually with 
the implied statement that some or most of the harmful 
ingredients of coffee have been removed. After a comparison 
of some of these with three types of pure coffee the following 
statement has been made:^ 

'Kaffee Hag' is almost caffein-free but contains the normal 
amount of caffetannic acid. * George Washington Coffee' 
(a soluble, concentrated coffee) contains about four times as 
much caffein and caffetannic acid as normal coffee. *Cafe 
des Invahdes' contains about 80 per cent, as much caffein as 
ordinary coffee, the decrease being due to its dilution with 
other vegetable substances; its caffetannic acid is somewhat 
higher than in normal coffee. 'Richelieu Vacuum Coffee' 
contains practically the same amount of caffein and caffe- 
tannic acid as ordinary coffee." 

Certain coffee substitutes prepared from roasted grains are 
sold for the use of those who desire a beverage simulating 

^ Aborn: Tea and Coffee Trade Jour., 1913, xxv, 568. 

2 Food Products and Drugs, Report of Conn. Agr. Exp. Sta., 191 1, Pt. 5. 



216 FOODS VALUABLE FOR SALTS AND WATER 

coffee but who do not wish to ingest the alkaloid cafFein. 
These products accomplish this end more or less satis- 
factorily, although their action is chiefly that of a warm 
beverage. 

The general effect of tea or coffee is to produce wakefulness 
and relief from fatigue, increased strength and rapidity of the 
heart beat and increased blood-pressure. In some people 
drowsiness rather than wakefulness is induced by coffee: this 
is usually followed by a period of wakefulness. These effects 
are to be ascribed chiefly to the caffein contained in them; 
caffein also has a diuretic effect. The feeling of well-being 
which accompanies the ingestion of coffee after a meal has 
been ascribed as due to the local action of the contained 
oils. 

The effect of coffee upon digestion is to increase the 
period of gastric digestion without affecting it quantitatively. 
Since the direct effect of water when taken with food is to 
delay evacuation of the stomach, the best results are obtained 
when water and other liquids are taken after food rather 
than when mixed with it. On the other hand, the ingestion 
of bread or cake with coffee is desirable, for they prolong the 
feehng of satiety and delay diuresis. Coffee infusion has 
been found to tend to inhibit the coagulation of milk and to 
inhibit peptic activity outside the body while tea has a less 
retarding action on coagulation and appears to promote 
peptic activity. 

The harmful effects of tea and coffee are sometimes referred 
to the tannin content because tannic acid precipitates pro- 
tein, simple protein cleavage products, and digestive enzymes. 
The work performed for the Lancet tends to show for tea, at 
least, that in good teas the tannin is so combined with caffein 
that it will be precipitated out by the gastric juice and only 
become absorbable in the intestine in which the alkaline tan- 
nate would not have the precipitating power of tannic acid. 
They are therefore inclined to ascribe the harmful effect of tea 
to caffein. 

The slight laxative effect of hot drinks is probably to be 
ascribed chiefly to the hot water. 

Cocoa and Chocolate. — Cocoa and chocolate are prepared 
from the seed or bean of the tree Theohroma cacao. The beans 
are removed from the pod, fermented in boxes or in holes in the 
ground, and then dried in the sun until they assume the char- 
acteristic brown color of the beans shipped to the market. In 
the preparation of the products cocoa and chocolate the dried 
beans are cleaned, roasted, crushed, and finally ground, after 
which the ground mass is molded or specially treated according 



BEVERAGES 217 

to the nature of the final product — chocolate or a special variety 
of chocolate such as milk chocolate or cocoa. It is during the 
fermentation processes just after picking and the subsequent 
roasting processes that care must be taken if the product is 
to develop the most desirable flavor. 

Ground cocoa nibs, obtained by crushing the roasted beans, 
constitute the ordinary chocolate of commerce. Sugar, dried 
milk, flavoring extract (particularly vanilla), etc., are added 
to the ground mass in the preparation of sweet chocolate, milk 
chocolate, etc. 

In preparing cocoa a portion of the oil or fat is removed 
from the ground seeds. This fat is removed by pressure — 
usually when warmed slightly; the residue is the finely pulver- 
ized cocoa of commerce. The expressed fatty material is cocoa 
butter, a semisolid fat used in the manufacture of chocolate and 
particularly in pharmaceutical preparations. AlkaUne salts, 
sodium, potassium or ammonium carbonate, are often added 
to the ground cocoa ostensibly to increase the solubility 
of the product; such products are sometimes designated 
as "Dutch process" cocoa. The addition of alkaU neutralizes 
any fatty acid present. Tests of these preparations in com- 
parison with untreated preparations have failed to show any 
marked increase in solubility; such treatment would tend, 
however, to aid in the emulsification of the cocoa fat and thus 
produce an apparent increase in solubility. 

Specially prepared cocoas are sold which have been treated 
with alkafi as indicated above or with the addition of sugar, 
starch, etc. 

Comparative Composition of Products of the Cocoa Bean.^ 





Cocoa 


nibs. 


Chocolate. 




Cocoa 






Original 




Original 




Original 






material. 


Fat-free. 


material. 


Fat-free. 


material. 


Fat-free 


Ash . . 


3-32 


6.66 


315 


6.59 


5-49 


7-49 


Soluble ash i . i6 


2.33 


1. 41 


2 


95 


2.82 


3-85 


Sand . 


0.02 


0.04 


0.06 





13 


0.24 


0.32 


Nitrogen 


2.38 


4-77 


2.26 


4 


73 


3-33 


4-54 


Fat . . 


50.12 




52.19 






26.69 




Fiber . 


2.64 


529 


2.86 


5 


98 


4.48 


6. II 


Starch . 


8.07 


16.18 


8. II 


16 


75 


II. 14 


5.20 



Cocoa and chocolate diflPer, as indicated above, particu- 
larly in the quantity of fat present. Cocoa contains roughly 
one-half as much fat as chocolate. The fat is largely a mix- 
ture of the glycerol esters of palmitic, stearic, lauric and ara- 
chidic acids, melting-point 38 to° 33° C. 

The active principle of cocoa and chocolate is theobromine, 

^Winton: Conn. Agr. Exp. Sta. Report, 1902, p. 282. 



^18 FOODS VALUABLE FOR SALTS AND WATER 

or trimethylxanthin, and is closely related chemically to the 
caffein of tea and coffee. There is roughly about as much theo- 
bromine in cocoa as there is caffein in tea or coffee, between 
I and 2 per cent., less in the specially prepared products because 
of the dilution with other substances; a small amount of caffein 
is present. Tannin is also present; the reddish color of the 
finished product has been held to be an oxidation product of 
the tannin present in the raw bean. 

Cocoa and chocolate contain theobromine which does not 
have the stimulating power of caffein, and these drinks are 
therefore less objectionable from that point of view. Because 
of the high fat content they tend to retard the passage of 
food from the stomach. While these beverages are prepared 
from substances with a high food value the prepared liquid 
is comparatively low in such value because of the relatively 
small quantity of material used; the added milk is often of 
more importance. 

Mineral Waters. — Water may be roughly divided for conven- 
ience into three classes: hard, soft, and ^^mineral" water. The 
presence of considerable quantities of the salts of the alkaline 
earth metals, particularly calcium and magnesium, is the chief 
characteristic of a hard water. Water analysts recognize two 
degrees of hardness: temporary and permanent. The quantity 
of calcium and magnesium present in water as the bicarbonate 
which may be precipitated through the removal of carbon 
dioxide by boihng or by the addition of lime is an index of the 
temporary hardness of water. When combined with the chloride 
or sulphate radicle calcium and magnesium are not precipi- 
tated readily by heating and the water is said to be perma- 
nently hard.^ 

Soft waters are comparatively free from dissolved inorganic 
matter. Distilled water is an artificially prepared soft water 
and is free from inorganic salts; it may contain a certain 
amount of ammonia. Rain water, when properly collected 
is virtually free from inorganic salts. It often contains a 
certain amount of organic material, particularly when collected 
from the roof. 

The term ''mineral water" is applied to those naturally 
occurring (and also artificially prepared) waters rich in par- 
ticular salts or gases as distinguished from the usual table water 

^ The temporary hardness of water may be removed by adding to it a saturated 
solution of calcium hydroxide, "lime water." In the presence of calcium hydrox- 
ide the calcium bicarbonate is changed into normal calcium carbonate which 
precipitates, and in this way both the calcium of the water and the calcium of 
the added lime water are removed. The quantity of lime water to be added to 
any water must be determined by experiment or it may be approximated from 
published analyses of the water under consideration. 



MVMAGES 219 

poor in such constituents and having no specific effect. The 
name has developed particularly in conjunction with the 
therapeutic use of such water. The classification of mineral 
waters has not been standardized. Since they are ordinarily 
used for their medicinal effect it is perhaps best to classify 
them according to the nature of the substance contained, as 
lithium water (lithia); sulphurous water; sulphate water 
(aperient); iron water (chalybeate); radio-active water. To 
these should be added the alkaline waters, a type which may 
include one or more of the types of water just named. Many 
waters are rich in sodium chloride and are sometimes desig- 
nated as saline waters. Some waters are naturally charged 
with carbon dioxide while others are sold artificially charged. 
The classification indicated above recognizes only the most 
characteristic constituent of mineral water; it may contain one 
or all of the other constituents. 

Lithium waters, or lithia waters, are waters which have been 
advocated because of the supposed solvent effect of lithium 
upon uric acid in the body. Consideration of the ionic equi- 
hbrium in the body makes it appear very improbable that the 
ingested lithium salts could dissolve uric acid to any consid- 
erable extent. Since most Hthia waters are comparatively 
poor in Hthium, large amounts of water would need to be 
taken to produce even a slight effect. 
. Sulphurous water contains hydrogen sulphide gas as the 
most characteristic constituent. The gas is liberated readily, 
unless properly bottled; to obtain hydrogen sulphide, there- 
fore, the water should be taken at the spring. The curative 
power of such waters is probably due to other constituents 
than the gas itself. It may be in the sulphur, sometimes 
"used as a blood purifier." Sulphurous waters are found at 
th&Anderson Sulphur Springs in California, French Lick Springs, 
Richfield Springs, and Cold Sulphur Springs. 

Sulphate waters are rich in alkali and alkali earth sulphates, 
such as sodium sulphate (Glauber's salt) and magnesium sul- 
phate (Epsom salt); these two salts usually occur together. 
Such waters are laxative and purgative, the efficiency varies 
with the amount of magnesium and sodium present. Many 
of these waters are concentrated by evaporation and are to 
be diluted or dissolved before using. Salts (sulphates) are 
sometimes added to the natural water to increase its concen- 
tration. Some American waters rich in sulphates are found 
at the Mendenhall Springs, Isham and Nuvida Springs in 
California; the Warm Springs, Hot Springs and Healing 
Springs in Virginia. Foreign waters such as Hunyadi Janos, 
Kissengen, Seidlitz and Friedrichshall are of this type. 



220 FOODS VALUABLE FOR SALTS AND WATER 

Iron waters usually contain other mineral constituents which 
may have as great an effect as the iron itself, such as carbon- 
ates, sulphates, Hthium, and arsenic. Many waters used as 
table waters are rich in iron. The presence of the associated 
salts must be considered in prescribing iron waters; a water 
containing bicarbonates is preferable as a tonic. The 
Berkely Springs, West Virginia, and the Round Spring at the 
Aurora Springs, Missouri, are examples of American iron- 
containing bicarbonate springs. Similar foreign waters are 
to be found at Spa, Belgium; St. Moritz, Switzerland; 
Schwalbach, Germany; Trubridge Wells and Flitwick Well, 
England. 

Radio-active Water. — The presence of traces of radium in 
certain waters has lead to their use in therapeutics. It has 
been found that such waters lose their radio-activity with 
time. Springs which have been advocated for their healing 
properties because of the presence of various salts have been 
found to be, in addition, radio-active. Many waters, such 
as those at Hot Springs, Arkansas, the mineral springs of 
Yellowstone Park in America, and the foreign waters at 
Carlsbad, Gastein, Wiesbaden, Kissengen and Bath have 
been found to be radio-active. Radio-active water is arti- 
ficially prepared and sold or may be prepared with suitable 
apparatus. 

Alkaline waters include particularly those of the lithium, 
sulphate and iron types. They are valuable as a means of 
administering alkaHne salts. The alkaUnity of these waters is 
due to the presence of bicarbonates, primarily of sodium, 
potassium, or lithium and secondarily of magnesium and cal- 
cium. Many alkaline waters are eflPervescent. Vichy water is 
perhaps the most generally used alkaline water. Some Ameri- 
can alkaline waters are: White Rock and Clysmic (Wakeshau, 
Wisconsin); Vichy (Saratoga Springs, New York); London- 
derry Spring (New Hampshire); Hot Springs (Arizona); Vichy 
(France); Carlsbad (Austria), and Fachingen (Germany) are 
alkaline European waters. 

An analysis of the various medical data with regard to the use 
of mineral water has brought out the following facts •} (a) many 
patients are improved in health under mineral water treat- 
ment; (b) waters of widely different composition have been 
recommended for the same disease; (c) curative properties 
are ascribed to many waters whose mineral content is the same 
as, or lower than, the city supplies used daily by many people 

1 R. B. Dole: The Production of Mineral Waters in 191 1, U. S. Geol. Survey, 
advance chapters for Mineral Resources of United States, 191 2. This discusson 
of water is taken in part from this paper. 



BEVERAGES 221 

without peculiar physiological effects; (d) treatment at resorts 
is often recommended for those afflicted with chronic organic 
diseases, many of which are obscure in nature or are caused 
by failure of nutrition. Such facts lead to the conclusion 
that the beneficial effects are to be ascribed more to the free 
use of water itself, augmented by dietetic treatment, exer- 
cise, and other hygienic restrictions and possibly change of 
climate and freedon from business and household cares than 
to the contained mineral constituents. 

The demonstration of the value of various waters will 
depend upon the concentration of the dissolved constituents. 
The determination of the effects of a particular water are 
difficult to demonstrate because of the difficulty in control- 
ing the physiological factors associated with their ingestion. 
The specific action of salts may occur in three ways: as stimu- 
lants to (a) increase or (b) depress the activities of an organ 
or function or (c) as irritants which cause a change in form, 
growth, and nutrition, rather than of activity. The action of 
mineral waters is due to the contained ions rather than to the 
undissociated salt. The effect of any particular ion will depend 
upon its associated acidic or basic radicle and the presence of 
other ions in solution. When two ions occur together one 
ion may neutrahze the effect of the other. Such an effect 
is apparently specific and not necessarily in the ratio of the 
combining power of the ions; thus, roughly, one part of cal- 
cium chloride will neutrahze or antagonize the effect of one 
hundred parts of sodium chloride in its effect upon the per- 
meability of membranes. This antagonistic action of ions 
may be the explanation of the tolerance of comparatively 
large quantities of some mineral waters. We know that a 
tolerance for a water is acquired; the development of diarrhea 
in some persons upon moving from one locality to another 
may be looked upon as of this nature.^ 

The fact that an individual dose of a salt is not harmful 
does not mean that its continued ingestion may not be injuri- 
ous, for small repeated doses of a salt will in some cases induce 
symptoms which are more marked than from a single dose, 
such as in lead poisoning, or an abnormal tolerance may be 
acquired as in the case of arsenic. 

Analyses of water do not tell the manner in which the 
various ions are combined but only their proportionate dis- 
tribution. From such analytical data we say by inference 
that the ions exist in certain combinations. These com- 
binations are hypothetical, for the complex combinations of 

^ Diarrhea may be due to infection from a water new to the individual. 



222 FOODS VALUABLE FOR SALTS AND WATER 

various salts and the effect of loss of dissolved gases, particu- 
larly carbon dioxide, alter the molecular and possibly ionic 
complexes actually present in the original water analyzed. 

The results of water analyses are usually expressed in parts 
per million. 

The following equivalents of certain methods of expressing 
analytical results will aid in understanding the significance of 
this expression: 

Equivalent in parts 
per million. 

I part in lOO i part in 10,000 

I part in 1000 i part in 1,000 

I gram in a liter i part in i ,000 

I milligram in a liter i part in i ,000 

Grains per imperial gallon -f- o . 07 gives parts per million. 
Grains per U. S. gallon -f- o . 058 gives parts per million. 

Dole has suggested the use of the quantity of a specific salt 
in four kilograms of water (the water intake for a day) as the 
basis of differentiation between medicinal and common water 
with reference to the minimum dose of the individual con- 
stituent in the absence of other ions which have a pharma- 
cological effect, ignoring as difl&cult of demonstration the 
effect of associated ions. 

The following table of the minimum dose of constituents 
common to mineral waters has been prepared by Dole: 

Average Equivalent 

minimum dose, concentration, 
Radicle. grams. mg. per kg. 

Arsenite (AsOs)) 1 (0.2 

Arsenate (ASO4)/ ^'^^^^ I 0.3 

Fluoride (F) 0.002 0.5 

Barium (Ba) 0.003 0-7 

Hydroxide (OH) 0.013 3-0 

Aluminum (Al) o.oii 3.02 

Iron (Fe) .r 0.024 6.0 

Lithium (Li) . . . ' 0.075 15.0 

Ammonium (NH4) 0.078 20.0 

Manganese (Mn) 0.12 30.0 

Metaborate (B02)\ .3N _ ^,- /30.0 

Pyroborate (B4O7)/ ^ ^ ........ 0.035 <^3o.o 

Iodide (I) 0.12 30.0 

Calcium (Ca) 0.2 50.0 

Magnesium (Mg) 0.2 50.0 

Orthophosphate (PO4) 0.23 50.0 

Carborate (CO3) 0.281 70.0 

Sulphite (SO3) 0.315 70.0 

Thiosulphate (S2O3) 0.300 70.0 

Nitrate (NO3) 0.5 100. o 

Bromide (Br) 0.53 100. o 

Sulphate (SO4) 0.60 150.0 

In preparing the table care was taken that the concentration 
expressed should represent a minimum below which thera- 

^ Equivalent as arsenic (As); -in acid solution; ^equivalent as boron (B). 



BEVERAGES 223 

peutic activity could not logically be attributed to the radicle 
in question. 

The significance of the last column may be illustrated as 
follows: If the average quantity 0.53 gram of bromine were 
in four kilograms of water the concentration of the radicle 
would be 132 milligrams per kilogram (reduced to 100 in 
the table), that is, a person who drank 4 kilograms of water 
containing 132 milligrams per milHon by weight of bromide 
might exhibit symptoms produced by bromides, if the water 
did not contain some other radicle which was antagonistic; 
530 kilograms, roughly quarts, of bromide water containing 
one part per million of bromine would have to be ingested to 
obtain a similar effect. 

Alcoholic Beverages. — Beverages containing alcohol are used 
chiefly for their psychological effects. They have, as a rule, a 
pleasant taste, often a fragrant odor, and are usually cooled, fac- 
tors which make their consumption a pleasure. In sufficient 
quantities their use is accompanied by pleasurable after-effects, a 
sense of exhiliration, relief from fatigue, and warmth, followed, 
however, in many cases by depression. The effect of moder- 
ate quantities, 30 to 40 c.c, of alcohol, is to quicken the heart 
beat without materially raising the blood-pressure; larger 
quantities produce a fall in blood-pressure except in certain 
abnormal conditions of the circulatory system, a result which 
is due to a depressant action on the nervous centers and in 
part to a weakened heart. The general effect is that of a 
narcotic rather than of a stimulant. There is an increased rate 
of respiration, disturbed heat regulation, and secretion of 
saliva and gastric juice. While alcohol produces, for the time 
being, a feeling of well-being and ability to work, these are 
more or less subjective effects. The true result appears to 
be a lowered capacity for work, particularly work requiring 
thought, and lessened endurance. 

A thorough and far-reaching study of the effect of alcohol 
upon the body processes is being undertaken' by Benedict in 
the nutrition laboratory of the Carnegie Institution of Wash- 
ington. This series of investigations has only been started. 
The results of a psychological study indicate that the period 
of response in the simple reflex arcs in the lumbar cord, the 
patellar reflex, and the protective-Hd reflex and to more com- 
plex cortical arcs, certain eye reactions to peripheral stimuli, 
speech reactions to visual word stimuli, and free associations 
were increased following the ingestion of doses of alcohol 
containing 30 c.c. and 45 c.c. of absolute alcohol; memory and 
free association were only slightly affected. 

As a food, alcohol is oiP the type of the energy-yielding food- 



224 FOODS VALUABLE FOR SALTS AND WATER 

stuffs, fats and carbohydrates. It can be substituted for them 
at least to a hmited extent and is capable of exerting a similar 
sparing effect upon protein. Its use must, however, be con- 
sidered in connection with the fact that alcohol has also a 
toxic effect foreign to fat and carbohydrate. It is not con- 
verted into sugar by the diabetic and may then become a 
source of energy. It is not, however, an antiketogenic sub- 
stance. The use of alcoholic beverages as food is of only 
secondary importance. Alcohol or even beverages fortified 
with sugar, such as some wines, are not economical sources of 
energy and there is no proof that alcohol itself is more effi- 
cient than carbohydrate in the body economy. The trend of 
the evidence is rather against such a possibiUty. Discussion 
of the use of alcohol as food has therefore little practical 
dietetic value; the food or fuel value of alcohol is a bone of 
contention between those advocating its use in general and 
their opponents. 

Studies of the food value of alcohol have shown that from 
90 to 98 per cent, of alcohol ingested in small quantities is 
oxidized; that the effect of the addition of the equivalent of 
500 calories in the form of alcohol, 72 grams, to a standard 
diet was practically identical with the addition of an equiva- 
lent amount of sugar, and that alcohol is not as efficient in 
sparing protein as carbohydrate or fat. Certain investigations 
have demonstrated in short experiments that for small amounts 
of alcohol there is an increased protein metaboHsm. Experi- 
ments of longer duration have shown that there is an initial 
rise in the nitrogen excretion (loss of protein) but that in the 
course of a few days the metaboHsm returns to the normal, 
or there may be a retention of nitrogen. The utilization of 
foods is unaffected by the ingestion oi small amounts of alcohol. 
These observations, which apply only to small quantities of 
alcohol, have demonstrated quite clearly that it may serve as 
a food. Large doses of alcohol exert a toxic effect, increase 
protein metaboHsm, and also the respiratory exchange; as 
the result of the restlessness of partially intoxicated per- 
sons. With complete intoxication the energy exchange is 
decreased. 

The desirability of using alcohol as a food under all cir- 
cumstances is doubtful; the associated danger of excessive 
consumption should certainly bar it as a constituent of the 
diet. While it can replace in part fats and carbohydrates it 
does not serve as a reserve food in the sense that these foods 
do, for it is oxidized immediately. 

The therapeutic use of alcoholic beverages in medicine, such 
as in the treatment of fevers on the basis that it is a readily 



BEVERAGES 



225 



assimilable and oxidizable type of food in a condition in which 
food is more or less contra-indicated, loses its importance some- 
what in the light of our present knowledge of the effect of 
food in such cases. With regard to the combined stimulating 
and food value of such beverages and their effect upon the 
appetite, Httle of a definite nature can be said. 

Alcoholic beverages are products obtained as the result of 
the alcoholic fermentation of sugar or prepared from fer- 
mented products. They are of two types, fermented and dis- 
tilled. Fermented liquors are the result of naturally occur- 
ring fermentations. Of these there are (a) the products of 
direct spontaneous fermentation of saccharine fruit juice, such 
as wine and cider, and (b) beverages produced from starch- 
bearing grains in which alcoholic fermentation takes place 
after the conversion of starch into sugar, and as the malted 
and brewed liquors, beer, ale, etc. 

Distilled liquors, sometimes designated as "spirits," such 
as whisky, brandy and rum, etc., are obtained by the distilla- 
tion of naturally fermented products. 



Composition of Alcoholic Liquors. 





6 
'2 
'x 
o 

a 

i 

3 


Alcohol. 


1 






1 


d 

"S 

T3 

B 
O 


Acidity. 


4 

< 






1 


1 

'o 
> 


03 
S 

o 

1 




6 
I 


3 


6 


Beer, lager .... 

Porter 

Ale 


0.4 
0.4 
0.5' 


4.3 
6.1 
5.7 


5.6 
7.7 
7.1 


4.2 
5.9 
4.4 

76.6 

3.67 
0.11 
0.67 
0.05 
36.00 


0.5 
0.8 
0.5 

3.1 


1.10 
0.57 
0.49 

65.40 
0.24 
3.00 
2.54 
1.92 

32.60 
0.04 


1.6 

2.8 
2.2 

6.9 







39 
29 
31 








02 
17 
16 
09 


0.06 
0.15 
0.12 

0.26 
0.60 
0.49 
0.43 
0.40 
3.36 
3.75 
1.92 

0.402 
0.21 


0.20 
0.37 
0.31 

1.20 
0.21 
0.50 
0.23 

0.41 

0.38 
0.32 


0.06 
0.05 
0.07 


Malt extract.i 

U. S. P 




0.56 


Claret 

Sherry 

Port ... . . 




9.7 
17.8 
18.1 

43;6 
41.1 
40.2 
38.5 

5.2 
1.4 


13> 
51.2 
48.5 
47.5 
52.0 

6.5 
1.7 


o!( 


)6 




Champagne .... 

Whisky 

Brandy 

Gin 

Liqueur 

Cider: 

Hard 

Sweet 


trace 





Fermented liquors, cider and wines, are beverages in which 
the alcohol is formed as the result of direct fermentation of 
fruit juices. Cider is the fermented juice of the apple. It 
contains from 3 to 8 per cent, of alcohol. Sweet cider is the 
freshly expressed juice and contains only small amounts of 
alcohol. Perry, or pear cider, is made from the pear. 



Dlastatic action complete in ten minutes. 
15 



2 As malic acid. 



226 FOODS VALUABLE FOR SALTS AND WATER 

Wines. — ^The term wine is customarily used to designate 
the fermented juice of the grape. A number of wines are to 
be had which diflPer particularly in their method of prepara- 
tion and to a certain extent according to the country or locality 
in which they are prepared. 

Classification of Wines. — A number of terms are used to 
express the type or quahty or variety of wines. ^ With regard 
to the method of preparation we have: Natural wines, wines 
which are prepared from the juice of the grape as expressed 
and to which no sugar or alcohol have been added, e. g., hock 
and claret; and fortified wines, to which alcohol has been 
added, usually before the natural fermentation is completed, 
e. g.y Madeira, sherry, port. According to the intrinsic prop- 
erties of wines we have the non-effervescing or still wines which 
contain little dissolved carbon dioxide; effervescing or spark- 
ling wines, more or less heavily charged with carbon dioxide 
(a) from natural fermentation of added sugar in the corked 
bottles — champagne; or (b) artificially charged with carbon 
dioxide; red wines, Burgundy and Bordeaux wines or claret; 
white wines, e. g., Rhenish and Moselle wine and sauternes; 
dry wines, in which the sugar has been exhausted by fermen- 
tation; and sweet wines, which possess a considerable 
amount of unfermented sugar and to which sugar is often 
added. 

Of the different varieties of wines champagne is an effer- 
vescing, selected, sweet, white wine fortified with sugar mixed 
with brandy. It contains 8 to lo per cent, of alcohol; claret 
is a light red wine somewhat acid and astringent, contains 
very little sugar, is high in volatile ethers, alcohol 8 to 13 
per cent.; Madeira is a strong white wine generally fortified 
with alcohol and possesses a rich, nutty, aromatic flavor, 
alcohol 17 to 20 per cent.; sherry, a Spanish wine, is a sweet 
wine sometimes fortified with alcohol, deep amber colored, 
slightly acid and possesses much fragrance, alcohol 8 to 20 
per cent.; hock, German wines, are white wines mildly acid, 
alcohol 9 to 12 per cent.; port, an astringent wine, always 
fortified with alcohol, dark purple in color, alcohol 15 to 18 
per cent. 

Malt Liquors (Beer, Ale, Porter, Stout). — Malt liquors are 
made by the alcoholic fermentation of malt with hops; other 
grains are sometimes added. To obtain the sugar from which 
the alcohol is to be formed, grain is malted; that is, it is per- 



1 The particular mode of preparation and more specific details of their compo- 
sition may be found by consulting such books as, Leach: Food Inspection and 
Analysis, New York, 1913. 



BEVERAGES 227 

mitted to sprout. In the processs of sprouting, starch is trans- 
formed in part into soluble sugars, particularly maltose^ the 
quantity of the enzyme, diastase, formed is often sufficient 
to change the starch of added grains, rice, corn, etc., to a 
considerable extent. The sprouting process is stopped at the 
proper point and the germinating mass is dried. The temper- 
ature at which the malt is dried determines to a large extent 
the depth of color of the final product; higher temperatures 
give the darker beers. In some cases carameHzation of the 
starch is permitted as in stout. To complete the conversion 
of the starch the dried malt and admixed grain, if there be 
any, are crushed and mixed with water to permit the diastase 
to continue its action. The saccharine liquor or wort is con- 
centrated, mixed with hops and a selected yeast and per- 
mitted to ferment. The nature of the yeast added for the 
alcoholic fermentation is a matter of great importance in the 
production of good malted liquors. After fermentation has pro- 
ceeded to the proper stage the beer is drawn off from the 
greater portion of the yeast and stored in casks or vats for an 
after-fermentation. When this process is completed the liquor 
is clarified and stored in casks or bottles. 

Of the different varieties of malt hquor we have beer, pre- 
pared as above without special modification; ale, essentially a 
light colored beer which usually contains more hops than 
beer; porter, a dark ale, and stout. The latter are prepared from 
roasted, partially caramelized malt. Such liquors are dark 
colored, usually heavy, and contain considerable quantities of 
dextrin and starch. 

Malt liquors contain in addition to water, alcohol, and 
sugar, a variety of substances formed in the processes of malt- 
ing and fermentation. Of these the carbon dioxide, which 
produces the effervescence, the volatile oils and the bitter 
principles which contribute to the taste are the most impor- 
tant; certain nitrogenous substances, chiefly peptone and amino- 
acids are also present. 

Malt Extracts. — True malt extracts are free from alcohol 
and contain the soluble principles of malt. Such extracts have 
a high percentage of sugar, maltose, 48 to 70 per cent., a 
certain proportion of dextrin, 2 to 16 per cent., and a high 
diastatic activity. Many of the malt extracts sold have been 
found to have the general characteristics of beer. Some 
have been analyzed which contained approximately from 2 to 
9 per cent, of alcohol. Such extracts have no diastatic activ- 
ity and their nutritive value depends essentially upon the 
sugar content, which is in many cases low. These extracts 
should not be compared with the U. S. P. malt extract 



228 FOODS VALUABLE FOR SALTS AND WATER 



described above. The following table gives the composition 
of commercial malt extracts in comparison with the U. S. P. 
extract. 

Analyses of twenty-one samples of commercial preparations 
sold as malt extract gave the following maximum and minimum 
values:^ 

Commercial Preparations. 

u. s. p. 

Maximum. Minimum. (for comparison). 

Alcohol 9 • 1 1 2 . 52 

Extract 15.32 5.39 76.6 

Ash 0.37 0.14 1.2 

Nitrogenous constituents, protein i . 09 o . 34 3.1 

Sugar solids 14.04 4.84 

Maltose 11. 17 1.41 65.4 

Dextrin 5.80 2.03 6.9 

Distilled Liquors. — Distilled liquors, as the name implies, are 
the product of the distillation of fermented liquors. By this 
process a liquor is obtained which is high in alcohol and con- 
tains in addition certain of the higher boiling-point alcohols, 
their esters, and acids which pass over with the alcohol. The 
distillation process is usually repeated and the intermediate 
portions taken for the best liquors, while the first and last 
distillates yield inferior products. The liquor obtained is 
harsh to the taste and must be stored for a time in casks and 
aged, to soften and refine their flavor. 

Whisky is the product of the distillation of fermented 
grains, usually mixtures of corn, wheat, and rye, which has 
been stored in casks for at least four years, alcohol content 
approximately 30 to 50 per cent. Brandy is the aged product 
of the distillation of fermented grape juice or wine. The 
term is sometimes applied to the distillation of the fermented 
juice of other fruits, alcohol 20 to 50 per cent. Cognac is a 
brandy distilled in certain parts of France. Rum is the dis- 
tillation from fermented molasses or cane juice, usually dis- 
tilled twice and stored for a long time. Gin is an alcoholic 
hquor flavored with the volatile oil of the juniper berry; other 
aromatic substances are sometimes used, such as coriander, 
anise, cardamom, orange-peel, fennel. Gin is water-clear and 
is kept in glass and not wood as are the other distilled liquors, 
alcohol 27.5 to 42.5 per cent. 

Liqueurs and cordials are manufactured beverages contain- 
ing a large proportion of alcohol, sugar, and essential oils. 
They are often highly colored. 

^ Conn. Agr. Exp. Sta. Report, 1914, p. 254, 



PART III. 

FEEDING IN INFANCY AND 
CHILDHOOD. 



CHAPTER XV. 

BREAST FEEDING— FEEDING NORMAL AND 
ABNORMAL CHILDREN. 



WOMAN'S MILK. 

Milk is a secretion of the mammary glands, but a few of its 
normal constituents are the result of transudation from the 
mother's blood. The composition of human milk is qualita- 
tively similar to cow's milk, but quantitatively quite different. 
Furthermore, women's milk varies in amount and compo- 
sition at different times, depending upon the length of time 
which has elapsed since the labor, upon the health of the 
mother, and upon whether or not the breasts are completely 
emptied at each nursing. 

Colostrum. — Colostrum is the term applied to the milk 
secreted during the first few days (i to 12) postpartum, before 
lactation is well established. Czerny and Keller include under 
this term all milk that shows evidence of absorption. Colos- 
trum is deep yellow in color, has an average specific gravity 
of about 1.040, a strongly alkaline reaction, and is coagulated 
by heat. Its composition varies considerably. The follow- 
ing table gives the average composition of five early colos- 
trums as compiled by Holt, Courtney and Fales:^ 

Average Composition of Five Colostrums (1 to 12 Days). 
Fat 2.83 



Lactose . 
Protein . 
Ash . . 
Total solids 



59 
25 

3077 
42 



The fat droplets of colostrum are more unequal in size than 
those of milk. Colostrum contains, besides the usual constit- 
uents of milk, many large nucleated granular bodies, called 
** colostrum corpuscles," which are about five times as large 

^Amer. Jour. Dis. Child., 1915, x, 229. 



230 BREAST FEEDING 

as ordinary leukocytes, contain many small fat droplets and 
have ameboid motion. They are present in large numbers for 
the first few days, rapidly disappear after lactation is well 
established, but reappear when lactation is interrupted. 
Czerny considers them leukocytes that appear when the 
breasts are not sufficiently emptied of milk and help in the 
absorption of fat. 

General Characteristics of Woman's Milk. — Woman's milk is 
bluish white in color, odorless and sweet to taste. Micro- 
scopically it shows many fine fat droplets which are smaller 
than most of the fat droplets in cow's milk. It contains a 
few epitheHal cells and leukocytes. The number of the latter 
is greatly increased when there is any inflammation of the 
breast. Its average specific gravity is 1.03 1, but it may vary 
between 1.026 and 1.036. 

Woman's milk is neutral or slightly alkaline in reaction; and 
is amphoteric. The latter condition is due to the presence of 
both mono- and diphosphates, the former being acid and the 
latter alkahne in reaction. 

The casein of woman's milk does not coagulate in such 
large clots as the casein of cow's milk. On the addition of 
acetic acid a fine flocculent precipitate is formed. Rennin 
alone does not coagulate it. 

Quantity. — The quantity of milk secreted increases rapidly 
for the first six to eight weeks, after this more slowly. To a cer- 
tain extent the quantity is governed by the demands of the 
infant. A large, vigorous infant will obtain more milk than a 
smaller, less vigorous infant. Furthermore, a wet-nurse will 
secrete more milk while nursing two or three infants than 
while nursing only one. 

The following table gives the average daily amount of milk 
drawn by an infant (from Czerny and Keller) '} 

Average weight The calcu- Average weight The calcu- 

Age of breast-fed lated day's Age of breast-fed lated day's 

in infants according amount of in infants according amount of 

weeks. to Camerer. milk. weeks. to Camerer. milk. 

gm. lb. and oz. gm. oz. gm. lb. and oz. gm. oz. 

1 . 3410 7 2 291 9.7 14 5745 II 15 870 29.0 

2 . 3550 7 6 549 18.3 15 5950 12 6 878 29.3 

3 . 3690 7 II 590 19.7 16 6150 12 13 893 29.8 

4 . 3980 8 5 652 21.7 17 6350 13 4 902 30-1 

5 • 4115 8 9 687 22.9 18 6405 13 5 911 30.4 

6 . 4260 8 14 736 24.5 19 6570 13 II 928 30.9 

7 . 4495 9 6 785 26.2 20 6740 14 I 947 31 -6 

8 . 4685 9 12 804 26.8 21 6885 14 5 956 31-7 

9 . 4915 10 4 815 27.2 22 7000 14 9 958 31-9 

10 . 5055 10 9 800 26.7 23 7150 14 14 970 32.3 

11 . 5285 II .. 808 26.9 24 7285 15 3 980 32.7 

12 . 5455 II 6 828 27.6 25 7405 15 7 990 330 

13 . 5615 II II 852 28.4 26 7500 15 10 1000 33.3 

Dcs Kindes Ernahrung, Ernahningsstorungcn und Ernahrimgstherapie, 



Leipzig und Wien, i, 353. 



WOMAN'S MILK 



231 



Composition. — Woman's milk varies widely in its composi- 
tion. Its principal ingredients are the same as those in cow's 
milk: namely, fat, lactose, protein, salts and water. The 
average composition is as follows: 



Average Composition of Woman's Milk. 



Fat . 

Lactose 

Protein 

Salts 

Water 



3-50 
7.00 
1.50 
0.21 
87.29 



Holt, Courtney and Fales^ divide lactation into four periods : 
the colostrum period (i to 12 days), the transition period 
(12 to 30 days), the mature period (i to 9 months), and the 
late period (10 to 20 months), and give the following figures 
as averages for these periods: 



Percentage Composition of Woman's Milk. 



No. of 
Period. analyses. Fat. 

Colostram, I-I2 days 5 2.83 

Transition, 1 2-30 days 6 4.37 

Mature, 1-9 mos. .17 3.26 

Late, 10-20 mos. .10 3.16 



Sugar. 


Pro- 
tein. 


Casein. 


Albumin. Ash. 


Total 
solids. 


7-59 
7-74 
7-50 
7-47 


2.25 
•1.56 

1.07 


0.43 
0.32 


.. 0.3077 

0.2407 

0.72 0.2062 

0.75 0.1978 


13-42 

13-39 
12.16 
12.18 



The sugar content remains practically constant throughout 
the entire period of lactation. Protein and ash are highest in 
the colostrum period and fall quite rapidly to the mature 
period, after which they vary little. The fat content is low- 
est in the colostrum period, rises rapidly in the transition 
period, and then falls in the mature period. These analyses 
of Holt, Courtney and Fales are particularly important, because 
many of their specimens were entire twenty-four-hour amounts. 

Fat. — The fat in human milk is held in permanent emulsion. 
The average percentage of fat is 3.5 or 4 per cent., but it may 
vary from 0.75 to 10 per cent. As a rule the amount of fat in the 
milk increases from the beginning to the end of each nursing. 

Volatile fatty acids form 2.5 per cent, of the total fat of 
woman's milk and 27 per cent, of the total fat of cow's milk. 
Oleic acid forms about 50 per cent, of the non-volatile fatty 
acids, the remainder being composed of myristic, palmitic and 
stearic acids. 

Lactose. — The percentage of lactose in woman's milk is more 
constant than that of the other constituents, being about 7 
per cent., which is nearly twice that of cow's milk. It is in 
solution. 

^ Loo. cit., 239. 



MgO. 


•P20S. 


NazO. 


K2O. 


CI. 


OIOI 


.0410 


.0453 


.0938 


.0568 


.0057 


.0404 


•0255 


.0709 


.0580 



232 BREAST FEEDING 

Protein. — The proteins of woman's milk comprise casein, 
which is insoluble in water, and lactalbumin and globulin, 
which are soluble in water. Besides these there are some 
nitrogenous substances which do not give the protein reac- 
tions. A large part of the latter is supposed to be urea. There 
is considerable difference of opinion as to the proportions of 
these substances. According to Talbot the probable division 
of the total nitrogen is as follows: "Casein 41 per cent., lactal- 
bumin and globulin 44 to 39 per cent., residual nitrogen 15 
to 20 per cent." Thus the lactalbumin and globulin form a 
much larger part of the total protein in woman's milk than they 
do in cow's milk. 

Salts. — The average ash content of woman's milk is less 
than a third that of cow's milk, being only 0.21 per cent. 
The following table gives the average salt content of 100 c.c. 
of woman's milk according to Holt, Courtney and Fales:^ 

Averages for the Different Periods. 

No of Total 
analyses, ash. CaO. 

Colostrum, 1-12 days 5 .3077 .0446 
Transition, 12-30 days 6 .2407 .0409 .0057 
Early mature, 1-4 

months ... 9 .2056 .0486 .0082 .0342 .0154 .0539 .0351 
Middle mature, 4-9 

months ... 8 .2069 0458 .0074 .0345 .0132 .0609 .0358 
Late milk, 10-20 

months ... 10 .1978 .0390 .0070 .0304 .0195 .0575 .0442 

The average percentage composition of the ash by the same 
investigation is as follows: 

Average Percentage Composition of Ash for the Different Periods. 

CaO. MgO. P2O5. NajO. K2O. CI. 

Colostrum . . . . . 14.2 3.5 12.5 13.7 28.1 20.6 

Transition 17.0 2.4 16.9 10.9 30.8 22.9 

Mature . . . . . . 23.3 3.7 16.6 7.2 28.3 16.5 

Late 19.8 3.6 15.5 10. 1 18.8 22.3 

Iron. — The iron content of woman's milk is about three 
times that of cow's milk. This makes the iron intake of an 
infant fed on diluted cow's milk much lower than that of a 
breast-fed infant. 

Phosphorus. — Woman's milk contains much less phos- 
phorus than cow's milk. About three-fourths of the phos- 
phorus of woman's milk is in organic combination, as against 
one-fourth of that of cow's milk. 

Salts of Woman's and Cow's Milk. — The total ash content 
of cow's milk is about three and one-half times that of woman's 

1 Am. Jour. Dis. Child., 1915, x, 243, 245. 



WOMAN'S MILK 233 

milk. The proportion of the different salts is quite similar, 
the chief differences being in the larger amount of iron and 
the smaller amount of phosphorus in woman's milk. Holt, 
Courtney and Fales^ give the average composition as follows: 

Comparison of the Percentage Composition of the Ash of Woman's 
AND Cow's Milk. 

CaO. MgO. P2OS. NazO. K2O. CI. 

Mature woman's milk . . 23.3 3.7 16.6 7.2 28.3 16.5 

Cow's milk 23.5 2.8 26.5 7.2 24.9 13.6 

Bacteria.— A few bacteria, usually staphylococci, are found 
in the milk of healthy women. Typhoid bacilli have been 
demonstrated in the milk of a woman ill with typhoid fever. 
Syphilis can probably be transmitted by the milk when the 
breasts are apparently normal. Pathogenic bacteria may be 
present in the milk when the mother is suffering from a local 
infection of the breast or a general sepsis. 

Drugs. — Some drugs are excreted in woman's milk. They 
are alcohol, bromides, iodides, salicylates, mercury, calomel, 
antipyrin, arsenic, urotropin, the saline cathartics and sal- 
varsan. Probably morphine and atrophine also are excreted 
in woman's milk. Most of these are found in very minute 
amounts. 

Nervous Impressions. — Any severe, acute or prolonged ner- 
vous strain may so alter the mother's milk as to seriously 
upset the infant. For this reason it is important that a nurs- 
ing mother should lead a quiet life and avoid all nervous 
strain and excitement. Women that are prone to nervous 
disturbances, as hysteria, are seldom able to nurse their infants 
successfully. 

Menstruation. — Menstruation does not, as a rule, seriously 
affect the milk supply. Not infrequently the infant is uncom- 
fortable and has undigested stools at the onset. Only rarely 
is the disturbance more serious and prolonged. 

Pregnancy. — If a nursing mother becomes pregnant her milk 
rapidly deteriorates both in quantity and quality. Weaning 
is imperative. 

Transmission of Immunity. — An immune mother transmits 
her immunity to her nursing infant. 

Diet. — Within narrow limits the amount and composition 
of the milk may be altered by changes in the diet. The best 
results are obtained when the mother has been underfed, and 
the milk is abundant but poor in quaUty, especially in fat. 
Increasing the diet generally, but especially the fat and carbo- 
hydrate, will usually increase the fat content of the milk. 
When the fat is too high, reducing the fat and carbohydrate 

1 Am. Jour. Dis. Child., 1915, x, 246. 



234 BREAST FEEDING 

in the diet and increasing the mother's exercise will usually 
reduce the fat. Low protein can be overcome by increasing 
the diet when the mother has been underfed, but is rarely 
influenced when the mother is already receiving a plentiful 
diet. Reducing the diet and increasing the exercise will 
sometimes reduce a too high protein. The percentage of 
lactose in woman's milk is more constant than that of either 
the fat or the protein and is Httle influenced by diet. An 
increase in the fluid intake will often increase the quantity of 
milk. 

BREAST FEEDING 

The simplest and best way to feed an infant is to nurse it. 
No artificial food has been evolved which gives nearly as 
uniformly good results. Therefore every mother that can do 
so should nurse her infant. The great value of breast feeding 
as compared with artificial feeding is proved by the much 
higher mortahty rate among artificially fed infants. Lateiner, 
Me3^erhofer and Progulski^ found the mortahty at the Lem- 
berg clinic to be i6 per cent, of the breast fed and 34 per cent, 
of the artificially fed. Another factor of importance is the 
greater frequency of rickets among the artificially fed. With 
premature infants, full-term infants that are feeble and under- 
developed, and the occasional infant that is unable to digest 
cow's milk, breast milk is essential. Among the poor there is 
very little opposition to breast feeding, unless the mother is 
the wage-earner and has to be away from home during the 
day, and even these mothers usually nurse their infants night 
and morning. Among the well-to-do the mothers are less 
frequently able to nurse their infants and they find the fre- 
quent nursings and especially the restrictions which nursing 
places upon their time very irksome. 

Contra-indic- tions for Breast Feeding. — The most frequent 
contra-indication is insufl&cient milk, but every eff'ort should be 
made to increase the amount of milk before resorting to 
artificial feeding. 

Another important contra-indication is serious illness of the 
mother, as tuberculosis, typhoid fever, puerperal fever and 
mastitis. When a nursing mother develops an infectious dis- 
ease of short duration, as tonsillitis, she may stop nursing 
during the febrile stage and resume it later. The breasts 
should be emptied two or three times a da}^ by massage and 
the breast pump. Many women resume nursing in this way 
after intervals of as long as two weeks. 

^Oestcr: Sanitatsw., 1914, xxvi, i. 



BREAST FEEDING 235 

Frequently an infant is taken from the breast of a healthy 
mother and given a cow's milk mixture because he does not 
thrive or has indigestion. If the amount and quality of the 
mother's milk is insufficient and cannot be improved by diet 
and regulation of her mode of living, there is nothing else to 
do. When, however, the supply of milk is ample and the 
quality good, every effort should be made to adapt it to the 
infant before beginning artificial feeding, and in only rare 
instances is this impossible. 

Occasionally a nursing mother will become pregnant. When 
this occurs her milk deteriorates rapidly in amount and qual- 
ity. At first the infant stops gaining, later he loses weight. 
Artificial feeding should be begun at once. 

Intervals of Nursing. — Formerly an infant was nursed 
whenever he cried and appeared hungry, and this is today 
the usual procedure among the ignorant. Many such infants 
thrive and gain steadily, but they are usually irritable and 
frequently upset the entire household. Habits are soon formed 
by infants, and regularity of nursings is an important one. 
Six to eight hours after birth the infant is allowed to nurse 
for five minutes. After this the nursings are repeated every 
six hours for the first two days. When the breasts begin to 
secrete milk, which usually occurs on the third or fourth day, 
the intervals are shortened to three hours, with one nursing 
omitted at night. At the same time the length of time that the 
infant is allowed to nurse is increased to ten to fifteen minutes. 

From this time to the third month the infant should nurse 
at 6, 9, 12, 3, 6, 9 and once during the night, usually about 
2 A.M. Always after the fourth month and occasionally 
earlier the night feeding may be stopped. It is well to stop 
this feeding as soon as possible, as the long undisturbed sleep 
is good for both the mother and infant. After the fifth month 
the intervals may be lengthened to four hours and the number 
of nursings reduced to five. The hours will now be 6, lo, 2, 
6, lo. 

These intervals are somewhat longer than those frequently 
recommended for the first few months. Feeble and premature 
infants frequently do better when nursed every two or two and 
one-half hours. Normal infants, however, gain just as rapidly 
on three-hour intervals, which have the advantages of allowing 
the stomach to empty more completely between nursings, giv- 
ing the mother more freedom and lessening the likelihood of 
cracked nipples. Even four-hour intervals from the beginning 
are recommended by some physicians. 

Length of each Nursing. — After lactation is well established, 
most infants will nurse fifteen to twenty minutes each time for 



236 BREAST FEEDING 

the first few weeks. Later they will frequently be satisfied in 
ten minutes. An infant should never be allowed to nurse a few 
minutes, play a few minutes and then nurse again. They 
should be taught from the beginning to nurse steadily, with 
an occasional rest, until they are through. An infant should 
never be allowed to sleep in the same bed with his mother, 
as this encourages him to nurse frequently during the night. 
An infant should seldom be allowed to nurse more than twenty 
minutes. If he is not satisfied by this time, he is either taking 
too much or the supply of milk is scanty. Weighing him 
before and after nursing will settle this point. 

Mother^s Diet and Exercise.— A nursing mother should take 
a plentiful diet of easily digested food, with some extra fluid, 
as milk, egg and milk, cocoa or gruel in the middle of the 
morning and afternoon and before going to bed at night. 
Besides this she should drink a plentiful supply of water. 
She should avoid all articles of diet that are highly spiced, 
very rich or difficult of digestion, such as peppers, pickles, 
relishes, vinegar, rich puddings and sauces, lobster, crabs, 
Welsh rarebit, and excessive amounts of coff*ee, tea and alco- 
hol. Most nursing mothers can take moderate amounts of 
raw or cooked fruits and vegetables. Occasionally, however, 
even moderate amounts of fruit, especially the more acid ones 
such as grapefruit or green vegetables, particularly tomatoes 
and onions, will cause colic and indigestion in the infant. 
When this happens the particular fruit or vegetable causing 
the trouble should be omitted from the diet. If it is impos- 
sible to determine which fruit or vegetable is causing the 
trouble, it is well to omit all fruit and green vegetables until 
the infant is normal again. Then they may be resumed one 
at a time, the infant being watched for any return of the 
symptoms. In this way the cause of the disturbance can 
usually be identified and so eliminated. 

A nursing mother should be relieved, as far as possible, of 
all strenuous work and exercise. Moderate exercise, on the 
other hand, is essential for her health and counteracts the 
tendency to too rich milk. Walking in the open air is one of 
the best forms of exercise. 

More essential even than exercise is sufficient rest. She 
should have at least one long period of sleep during the night, 
and at least two hours of sleep during the day. The longer 
intervals between nursings and the early stopping of the 
night feeding all help toward this end. 

It is possible to influence the quantity and composition of 
the mother's milk to a considerable extent by altering her diet 
and mode of living. 



BREAST FEEDING 237 

If the quantity is too small the mother's diet should be 
increased, especially the amount of milk, eggs and meat. 
Also her water intake should be increased. Her exercise 
should be limited and sufficient rest assured. Frequently 
relieving her of the physical and mental strain of caring for 
the infant helps a great deal. If she is anemic, run down or 
unable to take sufficient food because of lack of appetite, 
appropriate medication is indicated. 

If the milk is too rich, which usually means a high fat and 
protein content, lessening the mother's diet (especially meat, 
eggs and milk), increasing the amount of water which she 
takes, and increasing her exercise will usually reduce the fat 
content of the milk. At the same time the infant may be 
given one-half ounce of sterile water before each breast feed- 
ing and the length of the nursing reduced or the interval 
between nursings increased. 

When the milk is poor in quahty, that is, has a low fat 
content, the procedure is the same as when it is insufficient, 
except that it is more important to increase the soHds in the 
mother's diet than the fluids. 

It is easier to correct an abundant supply of overrich milk 
than an insufficient supply of milk which is poor in quality. 

Vomiting. — Most infants, whether breast or bottle fed, will 
occasionally regurgitate small amounts, from a few drops to a 
teaspoonful or two. This is to be expected and need cause 
no alarm. When, however, a breast-fed infant vomits large 
amounts after a good many feedings, something is wrong either 
with the milk or the method of handling the infant. The 
possibility of pyloric stenosis must always be kept in mind. 
Not infrequently it is due to the infant's efforts to rid himself 
of air swallowed during the nursing. This is apt to happen 
when the infant is placed in his bed immediately after nurs- 
ing. C. H. Smith^ has demonstrated that under these cir- 
cumstances the gas is water-locked in the stomach, and an 
endeavor to belch it on the part of the infant is sure to cause 
some vomiting. If the infant is held erect for a minute or 
two after nursing he will belch the gas without losing any 
milk. 

Too much milk or too high fat will cause vomiting. The 
amount can be determined by weighing before and after nurs- 
ing. If the infant is taking too much, the length of the nurs- 
ing should be shortened. If analysis of the breast milk shows 
a too high fat content the mother's diet should be cut down 
glightly, especially the soHd food, and her water intake and 

^Am. Jour. Dis. Child., 1915, ix, 261. 



238 BREAST FEEDING 

exercise increased. Also the infant may be given one-half 
ounce of sterile water before each nursing. 

Gas and Colic. — Both gas and colic occur much less often 
when an infant is breast fed than when he is artificially fed. 
The usual cause of gas has been explained in the previous 
section on vomiting. Occasionally certain articles in the 
mother's diet will cause coHc in the infant. The most frequent 
are the raw acid fruits and green vegetables. The method of 
handhng this situation has been explained in the section on 
the mother's diet. 

Abnormal Stools. — Constipation is unusual in the breast-fed 
infant unless the milk is insufficient either in quaUty or 
quantity. 

Loose, too frequent stools, often containing considerable 
mucus accompanied by colic may occur when the mother is 
menstruating, after an indiscretion in diet on the mother's part, 
when the mother is suffering from an acute infection, or when 
the milk is not adapted to the particular infant. All but the 
last condition are transient and easily righted. If the milk is 
at fault the first thing to do is to determine the quantity taken 
by the infant and the composition of the milk. The quantity 
taken can be determined by weighing the infant before and 
after nursing. If the quantity is too great the length of each 
nursing should be shortened. 

If the composition of the milk is wrong an endeavor should 
be made to correct the fault by changing the mother's diet 
and routine as is explained in the section on the mother's 
diet. This is at times impossible, especially when the milk 
is both scanty and poor in quality. Unless some improvement 
is made within two weeks it is rarely wise to persist any longer. 

MIXED FEEDING 

When a woman has an insufficient supply of milk for her 
infant, supplementary feedings of cow's milk may be used. 
This is mixed feeding, and it is indicated whenever the breast 
milk is of good quality but insufficient in amount to properly 
nourish the infant. One of two procedures may be employed, 
either small bottle feedings may be given after each breast 
feeding, or bottle feedings may be substituted for some of the 
breast feedings. If the former method is followed the infant 
is given only one breast at a nursing. The amount of breast 
milk obtained is calculated by weighing the infant before and 
after nursing. Then a sufficient bottle feeding is given to 
make up the proper amount. As a rule it is not necessary to 
weigh the infant before and after nursing for more than a 



WEANING 239 

few daysr If the second method is chosen, one, two or three 
of the breast feedings are omitted and a full bottle feeding 
given at these times. At the breast feedings it is best to give 
the infant both breasts each time, as otherwise the long inter- 
vals between nursings tend to diminish the amount of milk 
secreted. It is rarely possible to keep up the supply of milk 
if the infant nurses less than four times in each twenty-four hours. 
There is a distinct advantage in always giving one bottle 
feeding a day to all breast-fed infants. By so doing they 
become accustomed to taking the bottle and their digestion 
becomes adapted to cow^s milk. Furthermore it allows the 
mother one long interval during the day in which she may 
rest or be out of doors. If at any time it becomes necessary 
to wean the infant suddenly it can be accomphshed with much 
less likelihood of disturbance. 

In beginning mixed feeding a relatively low formula should 
be used at first. A three-months-old infant should begin with 
about a 6 in 20 and a six-months-old infant with an 8 
in 20 mixture. The full amount for the infant's age may be 
given from the beginning. The strength of the formula may 
be increased quite rapidly, about an ounce of milk being added 
every three days, provided there are no evidences of indiges- 
tion, until the strength of the formula is proper for the infant's 

The advantages of mixed feeding over artificial feeding are 
that it gives the infant a considerable amount of breast milk, 
that it allows the infant to become accustomed to cow's milk 
gradually, and that it simplifies weaning. 

WEANING. 

Few women can nurse their infants to advantage after the 
eighth or ninth month, and many have to give supplementary 
feedings long before this. Where it is possible to obtain good 
cow's milk it is a distinct advantage to give the infant one 
bottle feeding a day after the third or fourth month. This 
accustoms the infant to the bottle and greatly lessens the 
difficulty of weaning if the latter becomes necessary at any 
time. Infants that have never had a bottle feeding until they 
are six months of age or older will frequently refuse it abso- 
lutely as long as they are given the breast at all and sometimes 
for several days, even after the breast feedings have been 
entirely stopped. During this time they lose weight rapidly 
and not infrequently develop considerable fever. Little is 
gained by forcing them to take the bottle under these cir- 
cumstances. The best method is to offer the bottle at the 



240 BREAST FEEDING 

regular intervals and take it away if refused. They always 
give in finally. No serious results follow this method. A 
three-months infant, on the other hand, soon becomes accus- 
tomed to taking one feeding from the bottle. 

The indications for early weaning are insufficient milk, 
severe illness of the mother, and pregnancy. When possible 
it is better to wean gradually. If the infant has been taking 
one bottle a day another of the same strength is added and 
after a few days another until all of the breast feedings have 
been stopped. The rapidity with which this is done will 
depend upon the cause of the weaning and the amount of 
milk which the mother has. If the infant is already taking a 
bottle feeding, the other feedings should be of the same strength. 
If the infant has never taken any cow's milk the first formula 
should be considerably weaker than a normal artificially fed 
infant of the same age would be taking. After the first few 
days the strength of the formula should be gradually increased 
until the food is sufliicient for the infant. When it is neces- 
sary to stop all breast feedings at once it is more important 
to begin with a relatively weaker formula than when the bottle 
feedings can be gradually substituted. 

When the mother is able to nurse the full eight or nine 
months the process is much simpler. The various foods other 
than milk are added to the diet in the same order and amounts 
as with the artificially fed infant, except that it is not neces- 
sary to make these additions quite as early. When cereal is 
begun, a small amount of cow's milk (i or 2 ounces) diluted 
with an equal volume of boiled water is given with the cereal. 
As the cereal is increased the strength and amount of milk is 
increased. Then one feeding of diluted milk is substituted for 
a breast feeding. If the mother is well and strong and has an 
abundant supply of milk she may be allowed to nurse to the 
twelfth or thirteenth month. When this is possible it may 
not be necessary to use bottles at all, the infant being weaned 
directly to the cup. In no normal case should bottles be 
continued after the fifteenth or sixteenth month. 



CHAPTER XVI. 

ARTIFICIAL FEEDING. 

FOOD REQUIREMENTS OF THE ARTIFICIALLY FED 

INFANT. 

Energy. — Repeated efforts have been made to formulate 
some law or laws by which the caloric requirements of a given 
infant could be calculated. The first work was based entirely 
upon the body weight. It was soon found that the caloric 
requirement per pound was considerably larger for thin infants 
than for well-nourished infants. Then it was suggested that 
the surface area, and not the body weight, was the governing 
factor. As it is obviously impossible actually to measure the 
surface area of all infants, different investigators have worked 
out formulae by which the surface area of infants can be cal- 
culated. The results obtained by this method are more uni- 
form than those obtained where the weight alone is consid- 
ered, but the calculations are too complicated to be of practical 
use in every-day practice. Recently it has been suggested 
that the caloric requirement of an infant varies directly with 
the mass of active protoplasmic tissue in the body. This 
would explain why a thin infant requires more calories than 
a fat infant of the same weight. Unfortunately we have no 
means of calculating the mass of active protoplasmic tissue 
in any Hving infant. 

Muscular exertion has a marked influence upon the require- 
ments of the infant. Hard crying may increase the energy 
output by lOO per cent. Thus a very active infant always 
requires more energy than a quiet, passive infant. 

For practical use the body weight must be the guide at 
present. The usually accepted requirement is lOO calories per 
kilo or 45 calories per pound of body weight for each twenty-four 
hours from the end of the second week to the ninth 
month. At the same time we must remember that a very 
thin infant will frequently require considerably more than 
lOO calories per kilo, while a very fat infant may gain and 
do well on considerably less. During the first two weeks 
the caloric requirement is considerably less than 45 calories 
per pound, averaging only about 30 calories. After the 
eighth month the requirement falls to about 40 calories per 
pound. 
i6 



242 ARTIFICIAL FEEDING 

Protein. — Protein is required by the infant to replace that 
lost in tissue waste and for the formation of new tissue in 
growth. This double demand makes the protein requirement 
of a growing infant relatively greater than that of an adult. 
Furthermore, as the most rapid growth takes place during 
the early months, the protein requirement is greatest during 
these months. Morse and Talbot^ say, "The average protein 
need of infants is at least 1.5 gram per kilogram, or 0.7 
gram per pound of body weight." In order to obtain this 
amount an infant must take nearly an ounce of cow's milk 
per pound of body weight. The generally accepted rule of 
one and a half ounces of cow's milk per pound of body weight 
furnishes considerably more than this amount. 

Almost all cow's milk mixtures contain more protein than 
woman's milk. This is especially true of whole-milk mixtures. 
The low fat content of the latter makes it necessary either to 
use a very high sugar content or to raise the protein consid- 
erably above the theoretical requirement in order to furnish 
the necessary calories. Thus the whole milk mixtures which 
are commonly used, contain about if ounces of milk per 
pound of body weight. 

Animal protein is more easily digested and more completely 
absorbed than vegetable protein. The protein of milk is 
most readily digested by infants, that of woman's milk more 
easily than that of cow's milk. 

Formerly most of the digestive disturbances of infants were 
attributed to the protein, but of late the tendency has been 
to minimize the importance of protein as a cause of indiges- 
tion. Some justification for the larger amounts of protein 
frequently fed in cow's milk mixtures is found in the smaller 
amounts of some essential animo-acids in the protein of cow's 
milk. 

Fat. — As fat furnishes approximately twice as many calories 
per gram as carbohydrate or protein, it is a very impor- 
tant element in the food, and small variations in the fat content 
of the food have a marked influence upon its energy value. 
In health from 90 to 98 per cent, of the fat in the food is 
absorbed. In digestive disturbances, especially those condi- 
tions which are associated with diarrhea, a much smaller 
portion of the fat ingested is absorbed. Durmg the first 
few days postpartum about one-half of the dried stool is 
composed of fat. Later the amount of fat in the stools falls 
rapidly and varies between 14 and 25 per cent, of the dried 
stool. 

1 Diseases of Nutrition and Infant Feeding, 1915, p. 201. 



THE ARTIFICIALLY FED INFANT 243 

There is considerable difference of opinion as to the amount 
of fat which a normal infant's food should contain. Many 
physicians use top milk mixtures and thus keep the fat con- 
tent of the food about twice that of the protein. Others use 
whole-milk mixtures which make the fat content of the food 
only slightly greater than the protein. Both methods have 
their advantages and disadvantages. An infant fed on the 
higher fat mixtures will gain more rapidly and be satisfied 
with smaller amounts of food, especially during the early 
months, than one fed on whole-milk mixtures. Furthermore, 
the higher fat content permits the use of smaller amounts of 
sugar, which is necessary in feeding infants with an intolerance 
for sugar. The disadvantage is that infants fed on high fat 
mixtures are more apt to have digestive disturbances. For this 
reason whole-milk mixtures with their lower fat contents are 
safer in the hands of those with comparatively little experience. 

Carbohydrate. — Sugar. — All milk contains lactose or milk- 
sugar. The sugar content of woman's milk is about 7.5 per 
cent., which is nearly twice that of cow's milk. When cow's 
milk is diluted its sugar content is still further reduced so that 
a considerable amount of sugar has to be added to cow's milk 
mixtures in order to bring their sugar content up to the 
required amount. As a rule sufficient sugar is added to make 
the sugar content of the mixture about 6 per cent., never 
more than 7 per cent. An infant fed on woman's milk receives 
slightly more calories in fat than in sugar, while an artificially 
fed infant taking cow's milk mixtures receives a rather large 
part of his calories in the form of sugar. 

Three sugars are used in infant feeding, lactose (milk-sugar), 
saccharose (cane-sugar), and maltose. All of these sugars are 
disaccharides and in the process of digestion they are broken 
down into monosaccharides. The rapidity with which they 
are absorbed differs and hence their effect upon intestinal 
fermentation and peristalsis. 

Lactose is more slowly absorbed than either maltose or 
saccharose. Its longer stay in the intestinal canal is supposed 
to favor the normal fermentation processes and thus to hold 
in check excessive putrefaction. Furthermore, it is slightly 
laxative. For these reasons it is the sugar of choice for feed- 
ing normal infants. Pure maltose is never used in feeding 
because of its cost. The maltose used is always a mixture of 
maltose with dextrin, the maltose forming about 50 per cent, 
of most of the preparations. The dextrin content is more 
variable. The following table taken from Morse and Talbot^ 

^ Diseases of Nutrition and Infant Feeding. Macmillan, 1915, p. 194. 



244 



ARTIFICIAL FEEDING 



Maltose, 


Dextrin, 


per cent. 


per cent. 


40.00 


60.00 


51.00 


47.00 


63 . 00-66 . 00 


8 . 00-9 . 00 


58.91 


1542 


57 10 


30.90 


58.88 


20.69 


49- 15 


18.80 



gives the percentage of maltose and dextrin in the more 
common preparations used: 

Food. 
Loflund's nahrmaltose .... 
Mead's dextrimaltose .... 
Neutral maltose (Maltzyme Co.) 
Loflund's malt soup extract . 
Maltose (Walker-Gordon laboratory) 

Mellin's food 

Malted milk 

In digestion one molecule of maltose is split into two mole- 
cules of dextrose. For this reason it is more rapidly absorbed 
than either lactose or saccharose. This rapidity of absorption 
and the fact that some infants that have developed a fermen- 
tative diarrhea while taking lactose will digest maltose easier 
than lactose are the chief reasons for its use. 

Saccharose (cane-sugar) is split into dextrose and levulose 
in the process of digestion. As the levulose has to be changed 
into dextrose before being absorbed, cane-sugar is more slowly 
absorbed than maltose. Cane-sugar is somewhat less laxa- 
tive than lactose. Furthermore it is much cheaper than either 
of the other sugars. Many normal infants will thrive as well 
on cane-sugar as on lactose or maltose. Its cheapness is its 
chief recommendation. 

Starch. — Starch is used for two purposes in infant feeding, 
first, to prevent the formation of large casein curds in the. 
stomach, and second, to increase the strength of the food 
For the first purpose only a small amount of starch is neces- 
sary, 0.75 per cent, of starch in the food being as effective as 
larger amounts. This amount of starch may be added to the 
food of very young infants. 

After the second month some form of starch is usually 
added to most artificial mixtures. At first a cereal water, made 
by boiKng one level tablespoonful of either oat or barley 
flour and a pinch of salt in a pint of water for three-fourths 
of an hour, is used. After the fifth month two level table- 
spoonfuls of flour may be used. Barley water is generally 
beUeved to be sUghtly more constipating than oat water. 

Inorganic Salts. — The salt content of cow's milk is about 
three and one-half times that of woman's milk. The result is 
that the ordinary infant fed on diluted cow's milk receives a 
considerably greater amount of salts than a breast-fed infant. 
Furthermore, the relative proportions of the various salts 
diff'er somewhat in the two feedings, the chief difference being 
in the phosphoric acid. These differences are believed to 
have a considerable influence upon the growing infant, espe- 
cially in disturbances of digestion. 



PROPRIETARY FOODS 245 

The following table from Holt^ gives the relative percentage 
of the different salts in both cow's and woman's milk. 





Cow's. 


Woman's 


CaO 


22.8 


233 


MgO 


2.8 


3-7 


P2O5 


27.4 


16.6 


K2O 


24.7 


28.3 


NasO 


10.9 


7.2 


CI 


15-5 


16.5 



Water. — ^The amount of fluid required by an infant increases 
rapidly during the first three months and more slowly after 
that. A normal infant usually requires about 12 ounces at 
the end of the first week, 24 ounces at the end of the first 
month, 30 ounces by the end of the third month, 36 ounces 
by the fifth month, and 40 ounces by the eighth month. As 
a rule the fluid intake is about one-seventh of the body weight. 
As long as all the food is fluid, little additional water need 
be given, but as soon as part of the food is solid additional 
water must be given. 

PROPRIETARY FOODS. 

There are many so-called "infant foods" on the market. 
While these differ greatly in composition they all have cer- 
tain common characteristics. Almost all contain large 
amounts of carbohydrate and small amounts of fat and pro- 
tein. It is well to remember that similar mixtures can be 
produced with the usual ingredients of infants' food without 
using these proprietary preparations. 

They may be divided into four classes: first, those contain- 
ing cow's milk; second, those containing considerable amounts 
of maltose and dextrins; third, farinaceous foods; and fourth, 
miscellaneous preparations. 

Preparations Containing Cow's Milk. — This group includes 
the malted milks, Allenbury's milk food No. i and No. 2, and 
Nestle's food. The basis of all of these is milk that has been 
evaporated to dryness. All have considerable quantities of 
carbohydrate added. Their fat content is considerably higher 
than that of any of the other classes. 

Preparations Containing Large Amounts of Maltose. — 
Mellin's food which contains about 60 per cent, of maltose, 
is the best example of this group. Mead's dextrimaltose No. 
I contains about 52 per cent, of maltose. The malted milks 
are usually included in this group but their fat content is a 
great deal higher, due to the milk used in their manufacture. 
These foods may be used when maltose is indicated but should 
never be used without milk. 

^ Diseases of Infancy and Childhood, Appleton, 7th ed., 191 6, p. 150. 



246 



ARTIFICIAL FEEDING 



Farinaceous Foods. — This group includes imperial granum, 
Ridge's food, Robinson's barley and oat flour, Brook's barley 
flour, and the Cereo Company's flours. The group diff'ers 
from the first in that they contain almost no fat, and from the 
second in that they all contain considerable amounts of 
unchanged starch. The}^ may be used when it is desirable to 
add some carbohydrate partly in the form of starch to the 
food. The Cereo Company also furnish an enzyme preparation 
called cereo. By its use from 70 to 98 per cent, of the starch 
is converted into soluble carbohydrates. 

Miscellaneous Foods. — Eskay's albumenized food is made 
from egg albumen and cereals. Peptogenic milk powder is 
largely milk-sugar. 

The following table^ gives the composition of most of the 
foods mentioned: 



Name. 


Fat, 
per cent. 


Sugar, per cent. 


Protein, 
per cent. 


starch, 
per cent. 


Ash, 
p. c. 








' milk 


) ] 








Horlick's malted milk 


8.10 


67-95- 


malt 
^ dextrin 
milk 


|49-i5 
18.80^ 
42 . 00' 


15.00 




4.00 


Allenbury's food No. i 


13.80 


66.55- 


malt 
1 dextrin 
'milk 


14.00 
10.00^ 
36.00 


9.88 




398 


Allenbury's food No. 2 


14.20 


70 . 90 


malt 
dextrin 
" milk 


20.00 ■ 
13.00 

6.57 


9-75 




3-70 


Nestle 's food . 


5-70 


58.93 ■ 


cane 
malt 


25.0 

} 27.36 


11.94 


20.25 


1-45 








dextrin 








Mellin's food . 
Mead's dextrimaltose 
No. I .... 


1.80 


79-57' 
93 . 00 . 


fmalt 
1 dextrin 
1 malt 
1 dextrin 
'dex- 


58 -881 
20.69/ 
52.oo\ 

41.00/ 


II. 31 




4-45 
2.00 


Imperial granum . 


0.50 


1.80 • 


trose 
dextrin 


0.421 

1-38/ 


13.88 


72.79 


0.50 


Ridge's food . 


0-33 


2.96 




10.31 


70.93 


0.75 


Robinson's barley 


1.40 


2.92 




6.75 


70.20 


0.85 


Brook's barley 


1.03 


3-48 




8.69 


68.51 


0.88 


Cereo barley . 


2.03 


5.20 




14.88 


58.39 


1.48 


Cereo oat .... 


6.40 


2.36 




16.44 


56.31 


2.53 


Eskay's food . 


1.28 


55-8^{Srin 


54-i2\ 
1.70/ 


7-75 


31-95 


1.58 



ARTIFICIAL FEEDING. 

None of the rules for the artificial feeding of infants so far 
advanced apply to the newborn, because these infants are 

^ The figures for fat, protein, starch and ash in the above table arc taken from 
the Report of the Connecticut Agricultural Experiment Station, 1916, p. 328. 
Those for sugar are for the most part from Morse and Talbot: Diseases of Nutri- 
tion and Infant Feeding, 1915, p. 230. 



ARTIFICIAL FEEDING 247 

unable to digest cow's milk in sufficient strength or amount 
to satisfy completely their theoretical requirements. Hence 
we are forced to begin with such dilutions and amounts as 
experience has taught us are safe, and increase them as rap- 
idly as the infant's digestion will allow, until a sufficient 
amount of food is taken. After that the food may be calcu- 
lated with reference to the caloric requirement. 

For the first twenty-four to forty-eight hours many infants 
vomit repeatedly, especially when given any fluid. During 
this time it is best to give boiled water or a 5 per cent, 
solution of lactose in boiled water. One or two ounces should 
be given every three hours. After thirty-six hours, provided 
the vomiting has ceased, a weak dilution of milk may be given. 
Although many still use top-milk, mixtures, it is safer to use 
whole-milk dilutions with a small amount of lactose added. 
Infants fed on whole-milk mixtures do not gain as rapidly at 
first as those fed on top-milk mixtures. On the other hand, 
they are much less likely to become upset. 

The intervals between feedings should now be three hours, 
with one feeding omitted at night. The first formula^ should be 

Milk 2 ounces 

Milk-sugar 2 level tablespoonfuls 

Boiled water 18 ounces 

Method of Preparing Formula. — ^To make up a formula of 
whole milk the following articles are needed: 

Bottles — As many as there are feedings in twenty-four 

hours. They should be graduated in ounces. 
Measure — ^The best is an enamelware vessel marked on 
the inside in ounces and large enough to hold the 
entire twenty-four-hour amount. A glass graduate 
may be used but they break easily, especially if they 
are boiled. 
A small enamelware funnel. A tablespoon. Non-absorbent 
cotton. Milk. Lactose (milk-sugar). Boiled water. 
The bottles, measure, spoon and funnel should have been 
washed and boiled. 

The bottle of milk is well mixed so that the cream is evenly 
distributed and the desired amount of milk poured into the 
graduate. The desired amount of sugar is measured (three level 
tablespoonfuls equal one ounce), dissolved in part of the boiled 

^ All formulae in this section are made up to 20 ounces. This method has been 
adopted because it is simpler and more widely understood than the other methods. 
As soon as the total twenty-four-hour amount exceeds 20 ounces, one and a half 
times or double the formula is made up, depending upon the total amount of food 
required. 



248 ARTIFICIAL FEEDING 

water and added to the milk. Then boiled water is added to 
the mixture to make up the desired amount. It is now mixed 
and poured into the bottles, the proper amount for one feed- 
ing into each bottle. Finally the bottles are stoppered with 
cotton and placed in the ice-box. 

Increasing Formula.— The amount of milk and sugar in the 
formula can usually be increased every second or third day 
until the infant is taking 7 ounces of milk in each 20 ounces 
of food with two and one-half level tablespoonfuls of 
lactose added. After this the increase has to be slower. By 
the time the infant is two and a half months old he will usually 
be taking equal parts of milk and diluent with two and one- 
half tablespoonfuls of lactose added to each 20 ounces of food. 
While this increase in strength is taking place the amount is 
also gradually increased. It is best to begin by offering the 
infant i or 2 ounces at each feeding. Thus after the second 
day he will receive seven feedings of 2 ounces each, making 
14 ounces in each twenty-four hours. As soon as he is not 
satisfied with 2 ounces he may have more. The best method 
is to increase each feeding J ounce at a time. Such increases 
can usually be made about every five days until the infant 
is receiving 4 ounces at each feeding, making 28 ounces in 
each twenty-four hours. Most infants will reach this point 
about the fifth or sixth week. After this the amount may be 
slowly increased, reaching 5 ounces about the end of the 
third month, when the night feeding is usually dropped. 
At this time the infant will be receiving six feedings of 
5 ounces each, making 30 ounces in each twenty-four hours. 

The strength and amount of the food is still gradually 
increased so that by the fifth or sixth month the infant is 
taking 36 ounces of a mixture containing two-thirds milk and 
one-third diluent with i ounce of sugar added to the twenty- 
four-hour amount. It is well at this time to increase the 
intervals between feedings, so that the total twenty-four-hour 
amount is not lessened. Thus an infant who has been receiv- 
ing six feedings of 6 ounces each, i every three hours, will 
receive five feedings of 7 ounces each, one every four 
hours. 

From the sixth to the twelfth month the strength and 
amount of the food are increased very slowly. Most infants 
are taking whole milk undiluted and with no additions when 
they are ten to twelve months old. Delicate infants and those 
who have had digestive upsets frequently cannot digest whole 
milk until they are fifteen months old. The amount of each 
feeding is increased about an ounce each month until the 
infant is taking 40 to 45 ounces in each twent3^-four hours. 



CEREALS 249 

Usually this point is reached at eight or nine months. After 
this the increase is in the form of other food, the total amount 
of formula given being gradually reduced as the proportion of 
milk is increased. 

Cereal. — Frequently some cereal, usually barley water, is 
added to the food from the start. It is best to omit the cereal 
for the first two or three months in most cases, as its addition 
complicates the formula and adds one more factor which has 
to be considered when the food disagrees. After the third 
month it should be added, as it seldom disagrees by this time 
and, furthermore, it increases the carbohydrate content of the 
food slightly. The cereal most frequently used is barley, 
either as a flour or pearl barley. The desired amount of barley 
flour and a pinch of salt are brought to a boil in an amount 
of water slightly less than that used in the formula, and then 
simmered for three-quarters of an hour. It is then strained, 
partly cooled and added to the milk. After the fifth month a 
stronger cereal mixture is used. If pearl barley is used it has 
to be cooked much longer. In other respects its preparation 
is similar. 

If the infant is incHned to be constipated, oat water is pref- 
erable. There are several oat flours on the market. They 
are prepared exactly like barley flour. If oatmeal is used it 
should be cooked at least four hours. 

Some infants do better with imperial granum water prepared 
in the same way. It may be tried when barley and oatmeal 
cause colic or indigestion. A considerable portion of its carbo- 
hydrate content is in the form of dextrins. Many infants Hke 
its taste better than that of either oat or barley water. 

The table on page 250 gives the composition of a series of 
formulae such as have just been described with the approxi- 
mate age at which they should be used. While this table will 
serve as a guide it cannot be followed absolutely, as some 
infants will take more food or stronger food at the respective 
ages than that given in the table, and others will not be able 
to keep up to the schedule. Each infant has to be fed accord- 
ing to his individual needs and any schedule can serve as an 
approximate guide only. 

Dr. F. H. Bartlett has devised a ready method of compound- 
ing a formula for older infants. The caloric requirement of 
the infant is calculated by multiplying 45 (the required calories 
per pound) by the weight of the infant in pounds. From this 
he substracts 120 (the calories furnished by I ounce of 
sugar). The remainder he divides by 20 (the calories furnished 
by I ounce of whole milk). This gives the number of 
ounces of whole milk which the formula must contain. The 



250 



ARTIFICIAL FEEDING 















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HIGHER FAT MIXTURES ^51 

only remaining factors to be decided are the amount of food 
for each twenty-four hours, and the number and amount of 
the feedings. 

Suppose the formula required is for a healthy infant weigh- 
ing i6 pounds. The calculation is as follows: 

16X45 = 720. 720—120 = 600. 600 -^ 20 =30. 
Such an infant would take 40 ounces in twenty-four hours, 
divided into five feedings of 8 ounces each. So our formula 
would be 

Whole milk 30 ounces 

Milk-sugar i ounce 

Barley water 10 ounces 



\' 



40 ounces 



five feedings of 8 ounces each, one feeding every four hours. 

This method is easy to remember and is very satisfactory 
for infants after the third month. In the early months it 
allows more milk than most infants can take. 

Higher Fat Mixtures. — A good many healthy infants are 
able to take mixtures which contain more fat than the for- 
mulae given in the table on page 250. There are certain advan- 
tages in using such mixtures in some cases. They furnish the 
necessary number of calories with less milk than the whole 
milk formulae. Infants taking more fat are more easily satis- 
fied and usually gain more rapidly. Furthermore, the ten- 
dency to constipation is less marked with infants taking more 
fat. The chief disadvantage is that they are much more apt 
to upset the infant's digestion and to lead to a fat intolerance. 
Such an intolerance when once established may persist for a 
long time, necessitating the use of little fat over this period. 

By using the upper half of the milk in a quart bottle a 
milk containing 7 per cent, of fat may be obtained. Before 
removing the top milk the milk should stand in the bottle at 
least four hours. Then the top milk should be removed with 
a small dipper. It should not be poured off. After being 
removed it is mixed and the desired amount used to make up 
the formula just as with whole milk. 

It is seldom wise to use these top milk mixtures for very 
young infants, but after the third month a vigorous infant will 
usually thrive on them. A formula containing slightly less 
milk than the appropriate whole milk formula should be used. 
Each ounce of 7 per cent, milk in the formula furnishes 0.35 
per cent, of fat, while each ounce of 4 per cent, milk furnishes 
only 0.2 per cent, of fat. By using these higher fat mixtures 
the sugar content of the food can be reduced without lessening 



252 ARTIFICIAL FEEDING 

the caloric value of the food. This is desirable when feeding 
an infant with sugar intolerance. 

Food Other than Milk.— Orange Juice. — Artificially fed in- 
fants do better if fed food other than milk earlier than breast- 
-fed infants. This is especially true of those who are fed 
on pasteurized or sterilized milk. By the fifth month some 
fruit juice should be added to the diet. Orange juice is 
most frequently used. At first one teaspoonful of the juice 
diluted with an equal quantity of water is given one hour 
before one of the bottle feedings; usually the second feeding 
in the morning. The amount is gradually increased so that 
four to six weeks later the infant is taking ij to 2 ounces of 
orange juice each day. It does not have to be diluted after 
the first few days. Many infants do not Hke orange juice at 
first, but they soon take it readily. Its laxative qualities 
must be borne in mind and the number and character of the 
stools considered before increasing the amount. Often slight 
constipation can be controlled in this way. 

Beef Juice and Broth. — At seven months beef juice and 
broth are given, usually just before the noon bottle. At 
first one teaspoonful of beef juice diluted with an equal amount 
of warm boiled water and salted to taste is used. The amount 
may be gradually increased so that by the end of six weeks 
the infant is taking i or i^ ounces of beef juice every other day. 
Broth, either lamb or chicken, can be given on the alternate 
days. At first only J or i ounce at a time, but later as much 
as 4 or 5 ounces, should be given. 

Beef Juice. — Beef juice is made by searing a piece of lean 
beef, usually what is called "top round," and then squeezing 
out the juice in a small meat press. The fat will rise to the sur- 
face and may be skimmed off after it has stood a few minutes. 
A little salt is added and frequently an equal volume of warm 
boiled water. Boiling or other addition of too hot water coagu- 
lates the soluble proteins and therefore should be avoided. 
It should be freshly prepared. 

Cereals. — At eight months some cereal, besides that in the 
formula, should be added to the diet. Oatmeal is the one of 
choice in most cases, especially when the infant is constip^ated. 
It should be cooked in water at least four hours and then 
strained. Cream of wheat or farina may be used when there 
is a tendency to loose stools. They are prepared like oatmeal 
except that they do not need to be cooked more than two hours. 
At first a teaspoonful with a little of the formula poured over 
it is given at the time of the second bottle. The balance of the 
bottle is given immediately afterward. A few days later the 
same amount may be given with the 6 p.m. feeding. The 



BREAD 253 

amounts are gradually increased so that by the ninth month 
the infant is taking J or i ounce of cereal (i or 2 table- 
spoonfuls) twice a day. 

Egg. — At nine or ten months egg is given. The egg should 
be soft-boiled (two minutes) or coddled. At first only a little 
(i teaspoonful) of the white should be given. The amount 
is gradually increased and after a few days part of the yolk 
as well as the white is given. Some infants that cannot take 
soft-boiled or coddled eggs will take very finely grated hard- 
boiled eggs. The latter should be boiled thirty minutes. A 
few infants cannot take eggs in any form. Soon after inges- 
tion they vomit and frequently they develop an erythematous 
or urticarial eruption and fever. All egg should be withheld 
from these infants, until they are older when they may be 
immunized to egg as Schloss has suggested. 

Vegetables. — Vegetables may be given after the ninth 
month. The best vegetables to begin feeding are spinach, 
summer squash, asparagus, or celery. Later string beans, car- 
rots and lettuce may be added. All should be thoroughly 
cooked and then strained through a fine wire sieve. The 
resulting vegetable will resemble apple sauce in consistency. 
Of this one teaspoonful is given with the broth and egg 
at noon. The amount of the bottle feeding at this time 
should be gradually lessened as the other food is increased. 
The amount of vegetable may be gradually increased, so that 
the infant will be taking about a tablespoonful by the eleventh 
month. 

Rice and Potato. — By the tenth month rice or baked 
potato may be added to the noon feeding. The rice should 
be boiled at least four hours. The potato should be dry and 
mealy, never soggy. At first only a teaspoonful is given but 
this may be increased to one and one-half tablespoonfuls by the 
eleventh month. If the rice is given on the same day with 
the broth, it may be added to the latter, and on the alternate 
days the beef juice may be mixed with the' potato. 

Bread. — Bread or hard crackers, such as the Huntley and 
Palmer breakfast biscuits, may be given by the ninth or tenth 
month. The bread should be at least a day old, cut into thin 
slices and then dried on top of the stove until it is crisp and 
brittle. At first a small piece may be given with the 2 p.m. 
feeding, and later with the 10 a.m. and 6 p.m. feedings also. 

In the above schedules solid food has been added earlier 
than has been customary. The tendency of late, however, 
has been to feed solid food much earlier than formerly and 
certainly the results seem to warrant the change. While 
many of the infants do not gain as rapidly as when they are 



254 ARTIFICIAL FEEDING 

fed larger amounts of milk, especially when top-milk mixtures 
are used, they develop earlier and their bones and muscles are 
better formed and stronger. Furthermore, the tendency to 
rickets is much less marked in such children. 

The daily diet at twelve months of an infant fed in this 
way would be as follows: 
6 A.M. 8 ounces of milk. 
9 A.M. I or 2 ounces of orange juice. 

lo A.M. Cereal, i ounce (2 tablespoonfuls) ; 8 ounces of milk 
(part on cereal and balance in bottle); dry bread, 
I small piece. 
2 P.M. Beef juice, i or 2 ounces, or broth, 4 or 5 ounces; 
egg; boiled rice or baked potato, i ounce (2 level 
tablespoonfuls); green vegetable, J ounce (i level 
tablespoonful). 
6 p.m. Cereal, i ounce (2 tablespoonfuls); dry bread, i 

small piece; 8 ounces of milk. 
10 P.M. 8 ounces of milk. 

ABNORMAL SYMPTOMS. 

While the great majority of breast-fed infants go through 
the first year without any nutritional disturbance many arti- 
ficially fed infants have more or less trouble. In some cases 
the difficulty is easily rectified, in others it is more severe and 
may lead rapidly to death, or as more frequently happens, to 
a long chronic illness.. These differences are those of degree 
rather than of kind, as they all depend upon the inabiUty of 
the infant to digest one or more of the several ingredients of 
the food in the strength or amount furnished. Formerly the 
protein of cow's milk, especially the casein, was considered 
the most frequent cause of these disturbances of digestion, 
but recent evidence places the responsibility more frequently 
upon either the fat or the sugar. The condition is compli- 
cated by the fact that an infant who develops an intolerance 
for fat is likely soon to develop an intolerance for sugar, and 
vice versa, unless the first difficulty is promptly corrected. 
In many cases a carefully taken history will reveal the error 
which is at the bottom of the trouble If this is corrected at 
the beginning an immediate cure may be effected. Where the 
history reveals no such error and after the disturbance has 
persisted for some time the best method is to reduce markedly 
the strength of those ingredients that appear to be at fault. 
While the logical way to classify these cases is according to 
the particular food-stuff which causes the disturbance, the 
difficulties of following this scheme are so great that it has 



ABNORMAL SYMPTOMS 255 

seemed wiser to discuss different symptoms and their 
treatment. 

Vomiting. — The occasional regurgitation of small amounts, 
one or two teaspoonfuls, is of little importance. Holding the 
infant erect for a few minutes after he has finished taking his 
bottle enables him to belch what air he has swallowed with 
the feeding, and so eHminates the usual cause of regurgitation. 

Large amounts are vomited when the feedings are too large 
or the intervals between feedings too short. A normal infant 
should seldom be fed more frequently than every three hours 
and even longer intervals are more successful with infants that 
are inclined to vomit. 

Too high a content of fat in the food is a frequent cause of 
vomiting. In these cases it is aecessary to reduce the fat 
content of the food considerably below that proper for an 
infant of corresponding age and development. This is accom- 
plished by using partly or wholly skimmed milk in making 
up the food. After the vomiting has ceased the amount of 
fat in the food is gradually increased, but it is usually neces- 
sary to keep the fat slightly lower than normal for several weeks. 

Maltose preparations are more apt to aggravate vomiting 
than either lactose or cane-sugar. As a rule lactose is the best 
sugar. 

When the vomiting consists of large curds the addition to 
the formula of some alkali as sodium citrate (one grain for 
each ounce of milk is usually sufficient), or the use of a cereal 
water as diluent instead of plain boiled water will help to 
prevent the formation of large curds and lessen the vomiting. 

Gas.^ — All infants swallow more or less air while taking their 
feedings. In order that the infant may get rid of this it is 
well to hold him erect for a few minutes after the feeding is 
finished. 

Gas in the intestine is either air that has been passed on 
from the stomach or the result of fermentation. The first is 
prevented by the precedure mentioned above. The second is 
controlled by reducing the amounts of sugar and starch in 
the food or by changing to another kind of sugar. 

Colic. — Colic is a symptom of indigestion. Not infre- 
quently even a slight increase in the strength of the food will 
cause colic. In mild cases, dropping back to the previous for- 
mula will stop the colic. When the strength of the food is 
next increased a smaller addition should be made. In more 
severe cases the food should be diluted with an equal part of 
water, or even more, until the symptoms subside, and then 
gradually increased. Constipation is a frequent cause of colic. 
Its treatment is considered in a later section. 



256 ARTIFICIAL FEEDING 

Loose Stools. — Loose stools are the result of the infant's 
inability to digest one or more of the ingredients of the food. 
The sugar is the most frequent cause. From the previous his- 
tory and an inspection of the stools a conclusion as to which 
is at fault can frequently be arrived at. The formula should 
be made up without sugar, except what is in the milk, for a 
few days. As soon as the consistency of the stools has improved 
a small amount of sugar may be added to the food and grad- 
ually increased. If lactose has been used previously it is well 
to substitute cane-sugar or one of the dry preparations of 
maltose. 

At times the fat is the cause of the diarrhea. In these 
cases it should be reduced temporarily and gradually increased 
as the condition improves but the amount of fat in the food 
should be kept below the previous point for some time. 

Diarrhea. — All recent cases should have all food withheld 
for twelve to twenty-four hours. During this time boiled 
water or a thin cereal water should be given. The water may 
have a very little tea added and be sweetened with saccharine 
if the infant takes it better in this way. At least as much fluid 
as the infant usually takes should be given each twenty-four 
hours. If the infant will not take sufficient fluid, enteroclysis 
or hypodermoclysis may be used. For the latter an 0.8 per 
cent, salt solution is used; 150 to 200 c.c. may be given two 
or three times in each twenty-four hours. 

After twelve to twenty-four hours food should be given. 
In the less severe acute cases a formula made up of boiled 
skimmed milk without any additional sugar is frequently 
successful. The strength of the formula will depend on the 
age and condition of the infant. At first the amount of 
skimmed milk in the formula should not be more than one- 
third that of the milk in the previous formula. In the more 
severe cases better results are usually obtained by using 
buttermilk or protein milk. The buttermilk is diluted with 
water or cereal water and later may have fat and sugar added 
to it. It should not be boiled. 

Protein Milk. — Protein Milk (Eiweiss-Milch) is prepared as 
follows: One quart of whole milk is heated to 98° F. Two 
rennin tablets are dissolved in an ounce of cold water and 
mixed with the milk. The milk is now allowed to stand at 
room temperature until it has coagulated, which takes about 
twenty minutes. It is cut and allowed to drain through two 
thicknesses of gauze until the curd is very dry. The curd is then 
washed twice with cold boiled water. The dry curd is mashed 
in a mortar and then forced through a ver}^ fine wire sieve. 
This may have to be repeated several times. One pint of 
buttermilk is then gradually added to the curd. Finally suffi- 



ABNORMAL SYMPTOMS 257 

cient boiled water is added to make one quart. The composi- 
tion of protein milk made in this way is about as follows: fat, 
3.25 per cent.; sugar, 1.8 per cent.; proteins, 3.75 per cent.; 
salts, 0.65 per cent. Each ounce furnishes about 15 calories. 
Protein milk may be made from 2 per cent, milk when it 
will contain about 1.5 per cent. fat. For very young infants 
it may be diluted. That with the lower fat content is prefer- 
able for young infants. The advantages of protein milk are 
its low sugar content (1.8 per cent.) and its high protein con- 
tent (3.5 per cent.). For this reason it cannot be used for 
long periods without the addition of some sugar. The best 
sugar to give in this condition is maltose. It should be begun 
as soon as the stools are semisolid, at first only one teaspoon- 
ful in each twenty-four hours' food. Another teaspoonful may 
be added every second or third day^. 

It is seldom wise to keep these infants on protein milk for 
long periods. In changing them back to milk mixtures it is 
safer to begin with a formula containing less fat than the 
protein milk. Even then considerable difficulty is frequently 
experienced. Some of these infants will take unsweetened 
condensed milk better than ordinary milk. The unsweet- 
ened condensed milk is about two and one-fifth times as strong 
as ordinary milk and has to be diluted accordingly. Sugar 
has to be added to it as to ordinary milk. 

Constipation. — Constipation may be due to a too high fat 
content of the food, in which case the stools are large, dry and 
crumbly. Reducing the fat and increasing the carbohydrate, 
especially the starch content of the food, rectifies the condi- 
tion. On the other hand, a food which contains too little fat 
will cause constipation. In this case the stools are not so 
large and more normal in consistency. If the infant is strong 
and healthy a moderate increase in the fat will frequently 
relieve the condition. 

One or two ounces of orange juice daily will help. Lime 
water should be omitted from the food and milk of magnesia 
used if an alkali is necessary. Furthermore, lactose and mal- 
tose are more laxative than cane-sugar and oat flour is more 
laxative than barle}^ flour. 



17 



CHAPTER XVII. 

FEEDING OF THE PREMATURE INFANT. FEEDING 

AFTER THE FIRST YEAR. FEEDING DURING 

ACUTE ILLNESS AND IN NUTRITIONAL 

DISTURBANCES. 

FEEDING OF THE PREMATURE INFANT. 

For the first twenty-four to thirty-six hours a premature 
infant should receive only small amounts of a 3 per cent, 
solution of lactose at regular intervals. One or two drams 
(teaspoonfuls) is given every hour to a three-pound infant, and 
a slightly larger or smaller amount to a larger or smaller 
infant. As these infants are at first unable to suck they have 
to be fed with a medicine dropper or with a Breck feeder. 
The latter is a glass tube with a perforated nipple on one end 
and an unperforated nipple on the other end. The tube is 
filled with food, the perforated nipple held in the infant's 
mouth and the other nipple gently squeezed. This method is 
useful for the larger, better developed infants, but is of no use 
for the very small infants. The latter have to be fed by 
gavage, and great care must be used in feeding them, as they 
are apt to regurgitate and aspirate part of the food, especially 
when it is given too rapidly or in too large quantities. 

The best food for a premature infant is diluted breast milk. 
As the mother's milk secretion is usually insufficient for the 
first two or three weeks the milk must be obtained from 
another woman. It is not essential that her infant should be 
of the same age. At the same time everything possible should 
be done to stimulate the mother's milk secretion. Her breasts 
may be massaged arid pumped at regular intervals. A better 
method is to have the mother nurse a vigorous infant. 

Breast milk diluted with an equal amount of a 4 per cent, 
lactose solution is given after twenty-four to thirty-six hours. 
For very small infants the breast milk should be diluted with 
two parts of lactose solution. At first only two drams are 
given every hour. The amount is gradually increased to a 
half-ounce every hour, then an ounce every one and a half 
or two hours. At the same time the strength of the food is 
gradually increased. By the end of the second or third week 



FEEDING DURING THE SECOND YEAR 259 

the infant will be fed every two hours — 12 times in each 
twenty-four hours, the total amount of food for twenty-four 
hours being about 12 ounces. By this time the breast milk 
should be little, if any, diluted. 

As soon as the infant is able to suck, it should be given the 
breast for a few minutes, but if insufficient food is obtained 
from the breast the necessary amount should be given after- 
ward. When the infant obtains sufficient from the breast 
the other feedings may be stopped. 

When it is impossible to obtain woman's milk, cow's milk 
mixtures must be used. At first i ounce of milk and 19 ounces 
of a 4 per cent, lactose solution may be given. For very 
small infants the milk had best be partly skimmed at first. 
The amounts and intervals are the same as when breast milk 
is used, but the strength of the food has to be increased much 
more slowly. 

In feeding a premature infant it is important to remember 
that this food requirement is probably considerably less than 
that of a normal infant. 



FEEDING DURING THE SECOND YEAR. 

From the eleventh to the fifteenth month the schedule 
remains practically the same except that the 10 p.m. bottle 
can be stopped during the thirteenth or fourteenth month. 
It is often difficult to do this suddenly, but if water is gradu- 
ally substituted for milk the change is scarcely noticed. A 
good method is to pour off i ounce of the milk and add i 
ounce of water, the next night pour off 2 ounces of milk and 
add 2 ounces of water. After eight or nine days the entire 
feeding will consist of water. The amount of water may now 
be gradually reduced. 

At fifteen months the 6 a.m. bottle may be stopped and the 
breakfast given at 7.30 a.m., a small milk feeding being given 
just before the nap about 10.30 a.m. The orange juice may 
be given on waking or with the breakfast. At the same time 
the amounts of the different articles are slightly increased, 
and a greater variety of vegetables allowed. The daily schedule 
will now be as follows: 

6.30 A.M. Orange juice, 2 ounces (may be given with 7.30 

A.M. feeding). 
7.30 A.M. Cereal, i or ij ounces (2 or 3 tablespoonfuls); 

dry bread, i small slice; milk, 8 or 9 ounces, 
10.30 A.M. Milk, 7 or 8 ounces. 



260 FEEDING OF THE PREMATURE INFANT 

2.00 P.M. Beef juice, 2 ounces, or broth, 5 ounces; egg; 
boiled rice or baked potato, J ounce (i table- 
spoonful); green vegetables, J ounce (i table- 
spoonful); stewed fruit (prune pulp or apple 
sauce) i or I ounce (i or 2 tablespoonfuls) ; 
no milk. 

6.00 P.M. Cereal, i or i| ounces (2 or 3 tablespoonfuls); 
dry bread, i small slice; milk, 8 or 9 ounces. 

About the fifteenth or sixteenth month all bottle feedings 
can usually be stopped, all fluid being given from a cup. The 
6 A.M. bottle is stopped when the schedule is changed. A 
little later the breakfast bottle can be stopped, then the sup- 
per bottle and finally the 10.30 a.m. bottle. It is easier to 
stop them one at a time, rather than all at the same time. 
The 10.30 A.M. milk feeding can be stopped at about the six- 
teenth or seventeenth month. 

Meat is begun about the fifteenth month. At first only a 
half-teaspoonful with the 2 p.m. feeding. The amount is grad- 
ually increased so that by the eighteenth month about one- 
half ounce (i tablespoonful) is being taken. It is well to alter- 
nate meat and egg at first, meat and broth being given every 
second day, and egg and beef juice on the alternate days. 
Later the egg may be given with breakfast and meat given 
every day at 2 p.m. 

As the amount of solid food is increased during the second 
year, the quantity of milk is gradually reduced. Infants fed 
in this way rarely take much over 20 ounces of milk a day after 
the eighteenth month. This is important, as they will some- 
times refuse to take sufficient solid food as long as they are 
given large amounts of milk. This is especially true when the 
milk is given in a bottle. 

FEEDING AFTER THE SECOND YEAR. 

By the end of the second year a normal child should be 
taking only three meals a day, with at times a cup of milk in 
the middle of the forenoon, before the nap. Between meals 
only water should be given, but this may be given freely 
especially in hot weather. It may be cool but it should not be 
iced. About 20 ounces of milk should be taken each day 
equally divided between breakfast and supper. Up to the 
fourth or fifth year it should be warmed, but after that it 
may be given at room temperature. Dinner at 1.30 p.m. is 
the main meal and consists of 5 or 6 ounces of soup (broth 
or puree), or 2 or 3 ounces of beef juice, meat (lamb chop, 



FEEDING DURING ACUTE INFECTIONS 261 

steak, chicken, roast beef or lamb), potato (baked or mashed), 
or boiled rice, some green vegetable (asparagus tips, stewed 
celery, spinach, string beans, carrots, summer squash, or fresh 
peas), and some dessert — ^either cooked fruit (apple sauce, 
baked apple, stewed prunes, peaches or plums), or rice pud- 
ding, junket, custard, apple pudding, tapioca pudding or occa- 
sionally vanilla ice-cream, and one or two slices of bread and 
butter. No milk but only water should be given at dinner. 
Breakfast and supper are simple meals. Breakfast consists 
of some cooked cereal (oatmeal, pettijohn, cream of wheat or 
farina), a soft egg (soft-boiled, poached or scrambled), bread 
and butter and 8 to lo ounces of milk. If desirable some 
cooked fruit may be given at breakfast. Supper consists of 
cereal, bread or toast and butter, and 8 to lo ounces of milk. 
The daily schedule would be about as follows: 

7.30 to 8.00 A.M. Breakfast: 

Cooked fruit (i or 2 tablespoonfuls), if 
desired; cereal (3 or 4 tablespoonfuls); 
soft egg; bread or toast and butter; 
milk, 8 to 10 ounces. 
1. 00 P.M. Dinner: 

Soup, 6 ounces, or beef juice, 2 or 3 ounces; 
meat (i or 2 tablespoonfuls); baked 
potato or boiled rice, 2 or 3 tablespoon- 
fuls; green vegetable, 2 or 3 tablespoon- 
fuls; dessert or cooked fruit, 2 
tablespoonfuls; water. 
5.30 P.M. Supper: 

Cereal, 3 tablespoonfuls; bread or toast and 
butter; milk, 8 to 10 ounces; occasion- 
ally a soft-boiled egg or cooked fruit. 

FEEDING DURING ACUTE INFECTIONS. 

In feeding infants and young children during acute infec- 
tious diseases the important facts to be borne in mind are: 
first the great need of water, second the impairment of diges- 
tion, and third the fact that fats are not digested as readily as 
carbohydrates and proteins. 

Infants. — The total amount of fluid ingested should be kept 
up to the amount usually taken. More may be allowed if 
desired. It should be given in small amounts at frequent 
intervals between feedings. The food should be weaker than 
during health. For short' illnesses which last only a few days, 
simple dilutions of the previous food is usually sufficient. At 



262 FEEDING OF THE PREMATURE INFANT 

first the previous formula may be diluted one-half with boiled 
water or some cereal water. As the infant's condition improves 
the strength of the food may be gradually increased, but the 
full strength should not be reached until the temperature has been 
normal for two or three days. If the illness is of long duration 
the formula may be made up with partly skimmed milk and 
two-thirds or even all of the usual amount of sugar. In this way 
the fat may be reduced as much as desired while the protein and 
carbohydrate content of the food is only slightly reduced. 

Regular intervals of feeding are just as important with ill 
infants as with well infants. They should seldom be fed 
oftener than every three hours. Water, however, may be 
given freely between the feedings. 

Gavage. — Infants that are extremely prostrated, delirious 
or comatose frequently will not take sufficient food. If the 
condition perists for more than a few hours forcible feeding 
becomes necessary. Such infants may be fed by gavage. 

Children Over One Year. — Regular intervals of feedings are 
just as important as with infants. During the febrile stage 
they should be fed every three hours during the day and if ill for 
any length of time once during the night, making five or six 
feedings in each twenty-four hours. Water should be given 
freely between the feedings. It is important to keep the total 
twenty-four-hour amount of fluid well up to the usual intake or 
even above the same. A child of two years should take at least 30 
ounces, and one of four or five years 40 ounces in each twenty-four 
hours. If plain boiled water is not well taken, an alkaline 
water, as Vichy or Seltzer, may be given. During the febrile 
stage the diet may include broth, thin gruel, milk (diluted 
with water, Vichy or lime water), and albumen water (which 
may be flavored with orange juice). The gruels and milk 
furnish the most nourishment. Later cereals and dried bread 
may be added, then soft-boiled eggs and potato, and finally 
vegetables and stewed fruits. 

Gavage.^Delirious and comatose children may have to be 
fed by gavage. This can be done almost as easily as with 
infants by wrapping the child in a sheet. The food given 
may be predigested if advisable. Gavages should not be 
repeated oftener than four times in each twenty-four hours. 

Long Illness. — In illness associated with prolonged fever as 
tuberculosis the same general rules for diet apply as with 
adult patients. 

PYLORIC STENOSIS. 

In mild cases of pyloric stenosis dietetic treatment may 
be tried for a short time. If, however, some improvement 



PYLORIC STENOSIS 263 

is not quickly shown the case should be treated surgically. 
The best food according to Holt^ is breast milk with a low 
fat content. If necessary the breast milk may be skimmed. 
If breast milk cannot be obtained a low skimmed-milk 
formula should be tried. As the condition improves the 
amount of skimmed milk in the formula may be gradually 
increased until the formula is sufficiently strong for the infant's 
age except that the fat content is low. Then the fat may be 
slowly increased, but it should be kept lower than normal for 
several weeks or months. As a rule these infants do best on 
long intervals between feedings, usually four hours. The 
amount of each feeding should be small, at first not more 
than two ounces. Later it may be gradually increased to the 
proper amount for the infant's age. Small amounts of water 
should be given between the feedings. Holt says that occa- 
sionally a case does better on small amounts at frequent 
intervals, as one-half ounce every hour. This is especially 
true when breast milk is used. 

Morgan^ has given the best detailed statement of the post- 
operative treatment of these cases. His work is based on 50 
cases treated at the Babies' Hospital where the present routine 
is as follows: 

"The patient is given, an hour after operation, provided 
the recovery from the anesthetic has been complete, 16 c.c. 
of water, and an hour later 12 c.c. of breast milk mixed with 
4 c.c. of water. It may be necessary at first to use a medi- 
cine dropper for the administration. The breast milk is 
repeated every three hours, eight feedings a day, and is alter- 
nated with water. Both are gradually increased so that 
twenty-four hours after operation 16 to 24 c.c. of undiluted 
breast milk is being given every three hours and a similar 
amount of water between feedings. At the end of forty-eight 
hours the child is usually taking 20 to 30 c.c, at the end of 
seventy-two hours 30 to 45 c.c. at a feeding. The adminis- 
tration of water by mouth during the first three or four days 
is of the greatest importance. The time required to increase 
the milk to meet the caloric requirements of the child has been 
on an average five days; in small babies three days may be suffic 
ient, and in the well nourished as much as eight to ten days." 

Morgan emphasizes the importance of breast milk for these 
cases, at least for the first ten to twelve days after the opera- 
tion. If the mother has been nursing the infant before the 
operation every effort should be made to keep up her supply 

^ Jour. Am. Med. Assn., 1914, Ixii, 2014. 
2 Am. Jour. Dis. of Child., 1916, xi, 245. 



264 FEEDING OF THE PREMATURE INFANT 

of milk. The best method is to have her nurse a strong, healthy 
infant until her own infant is able to nurse again. If this is 
impossible her breasts should be massaged and emptied by 
means of a breast pump several times each day. Downes^ 
says that the infant may be given the breast forty-eight hours 
after operation. Morgan advises a longer delay of not more 
than seven days. If the mother is unable to nurse her infant 
a wet-nurse should be obtained when this is possible. When 
this cannot be done modified cow's milk may be gradually 
substituted for the breast milk, beginning on the twelfth 
day. At first the formula should be considerably weaker than 
that proper for the infant's age. 

CYCLIC VOMITING. 

The cause of periodic vomiting is probably some error in 
metabolism, but until the cause has been determined, the diet 
cannot be so regulated as to exclude it. The one factor com- 
mon to all cases is a well-marked acetonuria. In some cases 
the acetonuria appears very early, if not before the actual 
vomiting, in others the acetonuria does not appear until later, 
when it may well be the result of starvation. 

The dietetic treatment can best be considered under two 
headings: first that during an attack, and second, that during 
an interval. During an attack no food should be given by 
mouth. Water should be given freely either by mouth, by 
rectum or by hypodermoclysis. Small amounts may be tried 
by mouth, but if this aggravates the vomiting, as it usually 
does, it should be stopped. The best way is to give colon 
irrigations of one or two quarts of water every six to eight 
hours. The water should run in slowly, great care being taken 
not to overdistend the colon. A good method is to use an 
inlet and an outlet tube, the outlet tube being slightly larger 
and introduced two or three inches higher than the inlet. The 
amount of water retained can be calculated by measuring the 
amount allowed to flow in and the amount returning. At 
least 30 ounces should be retained in twenty-four hours. If 
insufficient water is retained from the irrigations, hypoder- 
moclyses should be given. In mild attacks normal saline may 
be used, but in severe attacks the use of a 2 or 3 per cent, 
solution of sodium bicarbonate helps to counteract the acid- 
osis. As the sterilization of solutions of sodium bicarbonate 
changes the latter into sodium carbonate, which is very irri- 
tating, it is necessary to change the carbonate back to the 

^ Jour. Am. Med. Assn., 1914, Ixii, 2019. 



CYCLIC VOMITING 265 

bicarbonate before using the solution. This is best accom- 
pHshed, according to Howland and Marriott, by passing a 
current of carbon dioxide under aseptic precautions through the 
cold sterilized solution, to which a few drops of a phenol- 
phthalein solution have been added, until all the pink color 
disappears. 

Alkali should be given in all cases, best as sodium bicar- 
bonate. It may be added to the water ingested, to the irriga- 
tions, or to the hypodermoclysis fluid. The endeavor should 
be to keep the urine alkaline. 

In protracted cases rectal feeding may be advisable. Four 
to 6 ounces of peptonized skimmed milk with 2 or 3 drams 
of sugar (dextrose) may be given every eight hours. 

When the vomiting has ceased for twelve hours, water may 
be given by mouth, at first in small amounts, J ounce 
every hour. If this is retained, a thin cereal gruel may be 
tried, beginning with a teaspoonful every half-hour and grad- 
ually increasing the amount. The kind of gruel used may be 
varied: arrowroot, cream of wheat and farina are all good. 
Later thick cereal and either Huntley and Palmer breakfast 
biscuits or dried bread may be added. Then broth, white of 
egg, fat free milk, strained vegetables and scraped meat. All 
fat should be withheld for some time. 

Between attacks the plan which has proved most success- 
ful in our hands has been to withhold all fats for long periods. 
The child is allowed the usual diet for his age, except that the 
milk is fat-free and no butter, olive oil or meat fat is allowed. 
In a study of one child, made by Dr. Helen Baldwin^ at the 
Presbyterian Hospital, the excretion of acetone bodies remained 
well within the normal limits as long as the child was confined 
to the above diet. The addition of even moderate amounts 
of butter fats to this diet caused a marked increase in the 
amount of acetone bodies excreted. 

Occasionally these patients show sensitization to some for- 
eign protein. Such proteins should be excluded from their 
diet, or an effort made to immunize the patient by feeding 
him gradually increasing amounts of the offending protein, 
according to the method devised by Schloss.^ 

Sufficient alkali, usually in the form of sodium bicarbonate 
should be given to keep the urine barely alkaline. 

After several months have elapsed without an attack, small 
amounts of fat may be added to the diet, but such additions 
should be considered experimental and should be stopped at 
the first evidence of a return of the trouble. 

^ Not published as yet. 

2 Am. Jour. Dis. of Child., 1912, iii, 341. 



266 RICKETS 



FEEDING IN NUTRITIONAL DISTURBANCES. 

Rickets. — Rickets is an extremely common disease, regard- 
ing the cause of which very Httle is known. The one known 
fact common to all cases of rickets is a very low calcium con- 
tent of the body, but why this occurs is not known. The 
amount of calcium in the food appears to be of little impor- 
tance, as all the ordinary cow's milk mixtures contain an 
abundance of calcium, much more than breast milk. 

Breast-fed infants develop rickets under two conditions: 
first, when they are kept on the breast exclusively much longer 
than usual; second, among the very poor, especially the 
Italians and negroes in the large cities of America. Much has 
been written about the poor surroundings of such infants, espe- 
cially the lack of sunUght and fresh air. Of possibly greater 
importance would seem to be the diet of the mothers, who 
eat very little fresh meat, milk, green vegetables and fresh 
fruit. Is it not possible that such a restricted diet deprives 
the mother's milk of something necessary to the infant for his 
proper growth .? 

Artificially fed infants are particularly apt to develop 
rickets when fed on the various proprietary foods, especially 
those that are made up without milk. A prolonged digestive 
disturbance in the first few months often precedes rickets in 
an infant that otherwise may be doing very well when the 
rickets develops. Finally many artificially fed infants develop 
rickets, usually of a mild type, in spite of having had proper 
cow's milk mixtures and without having experienced any 
digestive disturbance. 

These facts would suggest that even good cow's milk mix- 
tures are frequently insufficient in some particular. Further- 
more cases of rickets are self-limiting, and begin to recover 
about the time they receive a liberal mixed diet. Funk's sug- 
gestion that rickets is the result of a lack of certain accessory 
factors or vitamines in the diet, would seem to offer a pos- 
sible explanation, but it needs more proof than has been brought 
forward. At least it gives us a rational theory on which to 
base our treatment, and fortunatel}^ this coincides with the 
results of the best empiricism. 

The best prevention of rickets is breast feeding, but the 
mother's health should be watched and she should receive a 
liberal mixed diet, containing a fair amount of fresh meat, 
eggs, milk, green vegetables and fruit. When rickets develops 
very early good breast milk will probably do more to check 
its progress than any artificial feeding. 

With artificially fed infants all proprietary foods, especially 



FEEDING IN NUTRITIONAL DISTURBANCES 267 

those that are to be used without milk, should be avoided. 
Raw cow's milk mixtures, when it is possible to obtain a safe 
raw milk, are the best substitutes for human milk. Condensed 
milk should be avoided. When the milk supply is question- 
able it may be pasteurized, but it should not be boiled. If 
the infant's digestion is deranged he may be unable to take 
raw or pasteurized milk at first but he should be changed to 
them as soon as possible. 

Fortunately rickets rarely appears before the sixth month, 
and by that time the infant can be fed fruit juice and beef 
juice and a little later, egg, potato and green vegetables. All 
these articles should be begun in small quantities and gradu- 
ally increased as is explained in the section on feeding (p. 252), 
but they may be begun considerably earlier in a case of rickets 
than with a normal infant. 



PART IV. 
FEEDING IN DISEASE. 



INTRODUCTION. 

The intelligent use of foods in disease should become more 
and more a matter of interest, not only to the specialist but 
to the practitioner as well, and the time is far past when the 
conscientious physician can afford to turn over the diet regu- 
lation to the nurse, prompted by the patient's appetite or lack 
of it. As time has gone on we have come to recognize the 
importance of an adequate diet for the sick and the dangers 
which unnecessarily accrue to the patient from an insufficient 
supply of proper nourishment. With the tables of food values 
so generally at hand, the correct proportion of food elements, 
as well as the total food value necessary in a given case, may 
at least approximately be easily calculated. When the illness 
is slight or of short duration it is of course not so essential to 
go into minute details, but at least a general supervision should 
be kept of what the patient takes, even if a good deal of 
latitude is allowed in the choice of particular foods and 
drink. 

A sick person is proverbially difficult to please 'and when it 
comes to a matter of providing suitable food in a form that 
will appeal to such a patient, the difficulties are often nearly 
insuperable. Some simple rules might well be formulated to 
express the requirements of food and feeding in sickness. 

1. Food should all be as daintily prepared and served as 
possible, as much of the pleasure in food, as well as its proper 
digestion, lies in its manner of presentation to the patient. 

2. Food should be hot or cold as the patient prefers, iced, 
if necessary, but practically never served lukewarm. 

3. The seasoning of food should be carefully done, using 
preferably only the simplest condiments in minimal amounts, 
salt, pepper, celery salt. 

4. It should be served at regular intervals as nearly as 
possible. 



270 INTRODUCTION 

5. Only the easily digestible parts of foods should be pre- 
sented to a patient, as tender meats, young vegetables, etc. 
Avoidance of all well-known indigestible foods. 

6. All food should be thoroughly chewed and insalivated. 

7. The teeth and mouth should be kept in the best possible 
condition by tooth brush, mouth washes and cleaning of the 
tongue. 

8. Unless there is some special contra-indication, as in peptic 
ulcer, water should be regularly and freely given to the patient 
and a pitcher of water kept by the bedside for them to help 
themselves from when they are able to do so. 

9. A feeding cup or feeding spoon should be used in giving 
food to patients flat in bed, or if too ill to use the cup, fluids 
may be sucked through a glass tube. 

10. The physician, giving due regard to the patient's prefer- 
ances and appetite whenever possible, should be absolutely 
definite in his directions, preferably writing down intervals for 
feeding, definite quantities at each feeding, the foods to be 
used and whether they are to be given hot or cold. When the 
illness is apt to be prolonged and the patient's appetite no 
guide, feedings on a definite nitrogen and calorie basis should 
be prescribed in order to conserve the patient's strength and 
weight as much as possible. 

11. The services of a good nurse who is personally agree- 
able to the patient must be insisted upon, whenever the ill- 
ness is prolonged and finances permit. Such a nurse will be 
tactful in the care of the sick-room and feeding utensils. 



CHAPTER XVIII. 

DISEASES OF THE CIRCULATORY ORGANS. 

Diet in relation to diseases of the heart and bloodvessels is 
many-sided in that it must of necessity vary according to the 
particular condition under consideration, thus for example, 
in acute infections affecting the heart, the diet should be 
in accordance with the principles of diet in fever or acute 
infections. In myocarditis, coronary sclerosis or decompensa- 
tion of the heart from any cause, diet may be of extreme impor- 
tance by virtue of its possible adverse mechanical effects, giv- 
ing rise to dangerous or even fatal symptoms by pressure on 
the heart from the bulk of the food or from fermentation of 
the wrong kind of food. In arteriosclerosis food may act as a 
cause, in that overeating has a distinct etiological relation to 
this disease and by the increase in blood-pressure caused by 
certain foods and drink, either from quantity or quaHty, a 
cerebral hemorrhage may be precipitated. These specific effects 
must be noted in addition to the usual nutritive role of foods. 

FUNCTIONAL CARDIAC DISTURBANCES. 

Functional cardiac disturbances are frequently purely mat- 
ters of dietary regulation. Here the disturbance takes the 
form of either a tachycardia or an arrhythmia, and analysis of 
the diet may show the patient to be an excessive tea or coffee 
user or else to have a marked idiosyncrasy for these drinks. 
Gastro-intestinal disturbances are frequently at fault, usually 
accompanied by fermentation or confined gas, giving rise to a 
cardiac reflex through the vagus, producing extrasystoles. 

Sutherland^ puts it well when he says "more patients come 
to a doctor complaining of heart trouble when the digestion is 
at fault, than do those whose hearts are actually diseased." 

DIET IN ORGANIC CARDIAC DISEASE. 

Organic cardiac lesions may be acute or chronic, compen- 
sated or decompensated to varying degrees, and require special 
dietary consideration based upon these facts. 

^ System of Diet and Dietetics 



272 DISEASES OF THE CIRCULATORY ORGANS 

In the acute infections (endocardial or pericardial) the require- 
ments are much alike, and one tries to furnish the needed food 
requirements in such a form that they will be easily assimi- 
lated and promote excretion. Milk mixtures modified in vari- 
ous strengths, as often given in typhoid fever, are useful and 
fulfil the essential necessities, or a soft diet restricted as to 
amount. 

In compensated chronic valvular or myocardial disease, indi- 
viduals need food in the same proportion and amounts as do 
normal persons, provided they are in other respects normal. It 
is often a fact, however, that these people" have other concom- 
itant conditions which must be taken into account, such as 
chronic renal disease, with or without hypertension, obesity, 
arteriosclerosis, etc., any one of which compHcations must be 
the determining factor in prescribing a diet. In such cases 
the food must be ordered in obedience to the limitations set 
to the diet for these conditions. Overfeeding any case of 
chronic cardiac disease would be manifestly a mistake, as the 
resulting increase in body weight might completely change 
compensation to decompensation. On the other hand, these 
cases must be fully nourished in order to obtain the best 
mechanical result from a diseased organ and special attention 
given to preventing indigestion. 

Cardiac Decompensation. — In conditions of decompensation 
whether due to valvular lesion or myocarditis, diet is of great 
importance as already pointed out, and many systems of diet 
have been arranged for such cases. In the uncomplicated 
cases of mxild or only very moderately severe decompensation, 
much the same rules hold true as for the compensated hearts, 
stress being laid on the fact that indigestion in all its forms 
must he prevented, as an acute attack of indigestion may change 
the prognosis from a favorable one to a prompt exitus, par- 
ticularly in large, full-blooded individuals. The moderate 
restriction of fluids to prevent overfilHng of the vascular sys- 
tem must also be kept in mind, particularly at meals only 
small amounts of fluid should be allowed. When marked 
decompensation supervenes we are at once in the presence of 
complications. All the internal organs are congested, func- 
tionate at a disadvantage and often imperfectly; there is 
usually more or less subcutaneous edema and often collections 
of fluid in one or other of the body cavities; hence the indica- 
tion is imperative that we should do nothing to further handi- 
cap the patient. It is for this state of things that most of 
the so-called dietary cures for cardiac diseases have been 
devised, and among these there are some worthy of more 
detailed discussion. 



DIET IN ORGANIC CARDIAC DISEASE 



273 



The Karell Cure. — The Karell Cure^ is perhaps the oldest of 
these, although as originally published by Karell it is rather 
indefinite as to details. The idea of this diet and its many 
modifications is the same, namely, to furnish only a fraction 
of the daily food requirements by giving small quantities of milk 
for a time, then gradually increasing by adding other articles 
of food, keeping the total fluid intake down to 800 c.c. (26 oz.). 



12 A.M.; 4, 8 P.M.; 



mi 



Ik 



For the first five to seven days: 
200 c.c. (7 oz.). No other fluids. 
Milk as above. 

1 soft-boiled egg. 

2 pieces of dry toast. 
Milk as above. 

I soft-boiled egg and 2 pieces of dry toast. 
I egg and 2 pieces of dry toast. 
Milk as above. 
12 Noon. Chopped meat, rice boiled in milk, vegetables. 
6 P.M. I soft-boiled egg. 
Eleventh and Twelfth Days: Same as tenth day. 
No salt is used throughout the diet. Salt-free toast and 
butter used. A small amount of cracked ice is allowed with 
the diet. All meats can often be advantageously omitted. 

His explains the good eff'ect of the Karell cure on the 
following grounds : 



Eighth Day: 

10 A.M. 
6 P.M. 

Ninth Day: 

10 A.M. 
6 P.M. 

Tenth Day: 



I. 

2. 

3- 
4- 

5- 



The limitation of fluids. 

The low salt content of the diet. 

The elimination of toxins. 

Antitoxic eff'ect (against uremia). 

Mechanical (no distention). 
N. B. Potter tried the eff'ect of the Karell diet modified 
in various ways, keeping the total quantity at about 800 c.c. 
(26 oz.) for the twenty-four hours, and found that the results 
were almost, if not quite, as good as the original Karell diet, 
with the added advantage that it is less monotonous. 
Potter's Modifications of the Karell Diet. — '■ 

















Carbo- 










Calories. 


Protein. 


Fat. 


hydrate 


I. 


Skimmed milk 


800 c.c. 




303 


27.2 


2.4 


41.8 


2. 


Whole milk 


800 c.c. 




570-7 


26.4 


32.0 


40.0 


3- 


Whole milk 


700 c.c. 














30% cream 


100 c.c. 




806.9 


25-6 


58.0 


39-5 


4- 


No. 2+ Lactose 


oz. j (30 


gm.) 


685.4 


26.4 


32.0 


68.0 


5. 


No. 2 + 


oz. iij (90 


gm,) 


915.0 


26.4 


32.0 


124.0 


6. 


No. 2+ Oatmeal 


oz. j (cooked) 


588.7 


27.1 


32.1 


43-3 


7. 


No. 2 + 


oz. iij 




624.9 


28.7 


32.4 


49-9 


8. 


No. 3+ Lactose 


oz, j 




921.7 


25-6 


58.0 


67-5 


9. 


No. 3+ Oatmeal 


oz. j 




825.0 


26.4 


58.1 


42.8 


10. 


No. 8 + 


oz. j 




939-8 


26.4 


58.1 


70.8 


II. 


No. 3 + 

Lactose 


oz, iij 
oz. iij 




1205.6 


28.0 


58.4 


133-4 



^ Karell Diet, modified as used at New York Hospital, 
Jour., 1916, ciii, 450; Arch. Gen. de med., 1866, ii, 513, 
18 



Potter, New York Med. 



274 DISEASES OF THE CIRCULATORY ORGANS 

While on this diet the patients often lose their edema and 
compensation is restored, but the great disadvantage is, of 
course, that so little of real food value is given that the patients 
are insufficiently nourished and a considerable loss of body 
protein results — a thing in itself often disastrous when the 
patient is already undernourished. Its usefulness cannot be 
denied in certain cases, particularly of the sthenic type, but 
it must be used with caution, never forgetting that we are at 
the same time starving the patient and probably at longest 
it should only be used for a few days. There are various forms 
of restricted fluid intake, particularly as urged by Oertel and 
again by von Noorden, the former instituting practically a 
thirst cure and the latter recommending "thirst days" com- 
parable to the "green days" in his diabetic dietary regimen. 

Strauss^ recommends a moderate amount of protein, 72.8 
gm., and warns against the extreme reduction as seen in the 
Karell diet, except for a very short time. He also restricts, 
but only moderately, the fluid intake and advises against 
Kraus's routine of reducing the daily amount to 1500 c.c, 
then 1000 c.c. and later 800 c.c, which amounts to a thirst 
cure. These restrictions are all more advantageous when the 
decompensation is accompanied by high arterial tension. 
Many cases of decompensation when accompanied by general 
anasarca do well on one of the salt-poor diets as recommended 
in renal edema, great good often resulting from the limitation 
of the sodium chloride intake (see salt-poor diets) unless the 
decompensation is extreme and the general internal conges- 
tion excessive. This is often more generally and successfully 
used than the Karell diet, as the patients do not lose strength 
and muscle substance while on it. As one would naturally 
infer, its greatest usefulness is seen when there are renal 
complications. 

Carter^ published the results of Gaulston's sugar treatment 
for decompensation and a year later Dingle^ also reported a 
case. Both were cases of marked and progressive decompen- 
sation in which all the usual forms of diet and drugs had been 
tried without result. In each the success was marked and 
under similar conditions is certainly worth consideration. 
Carter recommends that the cane-sugar be given as follows: 
First week, 2 ounces daily. Second week, 3 ounces dail}^. 
Third and fourth weeks, 4 ounces, then gradually reduce 
to 3, 2 and I ounce. His diet is as follows: 

Breakfast: Coffee, ham, tongue, boiled egg, two pieces thin 
toast. No fat of any kind. 

^ Veroffent. d. balneol. Gcscllsch. in Berlin, 1912, xxxiii, 2, 27-37. 

2 Brit. Med. Journal, 191 1, No. 1401. ^ Ibid., 1912, i, 66. 



DIET IN ORGANIC CARDIAC DISEASE 275 

Luncheon: One piece dry toast, spring cabbage ( ?), broccoli 
or asparagus with boiled fish, boiled meat or boiled 
chicken (no fat or sauces). Rice boiled in a little 
milk or water, sugar being taken on the rice. No 
fruits or acid taken. A tumbler of hot water to be 
taken one hour before luncheon and dinner and 
nothing to drink at either meal. 
Afternoon Tea: Two pieces of dry bread with sugar on it 

and a little sugar in a cup of tea. 
Dinner: Much the same as luncheon, only a flaked cereal 
instead of rice on which to take the sugar. No fats, 
fruits or sauces. 
Physiologically this method of increasing the efficiency of 
the cardiac muscle seems reasonable, as the heart obtains^ at 
least one-third of its energy from carbohydrates. It is, how- 
ever, difficult to produce any hyperglycemia by means of 
the oral exhibition of sugar, so Biidingen^ has tried rectal and 
intravenous injections of an isotonic (5.4 per cent.) solution 
of glucose, with surprisingly good results in some instances. 
It is at least a method that deserves further trial, although 
hypodermic use of the glucose solution would seem a much 
simpler method to employ. 

Mackenzie insists that the food for cardiac cases shall be 
appetizing, nutritious, of small bulk, easily digested and thor- 
oughly masticated, and it might be added that in all cases, 
particularly in decompensation, the evening meal should be 
especially light. 

Fatty Heart. — Fatty heart is usually a part of a general 
adiposis, the heart being surrounded by an overcoat of fat 
with strands of fat even dipping in between the muscle bands. 
This gives a heart which has to work at a mechanical disad- 
vantage, often with the resulting symptoms of decompensa- 
tion, dyspnea on exertion, edema and palpitation. 

In the dietary treatment of this, the first object to be sought 
is a general reduction in body fat, which is best accomplished 
by one of the reduction cures. In these cases the Karell diet 
is especially useful and gives great satisfaction. Other 
methods are in accordance with the diets as suggested for 
reduction. 

Combined with any dietary routine there must go hand in 
hand a definite plan for the strengthening of the heart muscle 
by physical exercises, passive and active, for without this the 
reduction diets will leave the patient thinner, but with an 

1 Jour. Am. Med. Assn., 1914, p. 1895. 

2 Deutsch. Arch. f. klin. Med., 1914, cxiv, 534. 



276 DISEASES OF THE CIRCULATORY ORGANS 

entirely inefficient heart muscle, so that the second state is as 
bad as the first. For this purpose a sojourn at Nauheim is of 
great benefit if one can go abroad, or in this country much 
the same result can be obtained at home by artificial Nauheim 
baths and resistance exercises if given under expert direction. 
This regimen may be obtained at many of the American bath- 
ing resorts, among which may be mentioned Watkins Glen, 
The Chamberlain, Old Point Comfort, White Sulphur Springs, 
Battle Creek, etc. 

In many cases merely the resistance exercises strengthen 
the heart muscle satisfactorily and at the same time add to the 
general muscular improvement. 

Diet in Adolescent Heart and Cardiac Myasthenia following 
Infectious Disease. — This condition is seen not infrequently 
in young people who grow rapidly in a very short time, there 
being a disproportion between the circulatory organs and the 
more rapidly developing bones and muscles. The result is a 
heart which is not well up to the ordinary strain of daily life 
or slight increase in activities. 

A condition of real disease does not exist, but an asthenia 
affecting the heart, accompanied by palpitation, breathless- 
ness after exertion, or a feehng of weakness and lassitude. 
The dietary regulations designed to overcome this state are 
merely such as would meet the conditions of malnutrition 
following a prolonged disease, which has left the entire 
organism myasthenic, and include the giving of foods that are 
primarily nourishing, with the exclusion of all fancy dishes, 
salads and unnutritious foods. The food should be simply 
prepared, giving three meals a day with a small extra feeding 
between meals and at bedtime, if the appetite allows. Milk, 
cream and butter are valuable and a fair increase in protein 
should be insisted upon. With a regulation of the diet should 
be combined good hygiene and Hght exercise gradually increas- 
ing, always keeping below the patient's capacity. The use of 
the Nauheim resistance exercises does much to strengthen 
these hearts. 

Senile Heart. — ^The senile heart has received considerable 
attention at the hands of various authors, notably Balfour, 
who goes so far as to prescribe an absolute diet. It would 
seem, however, that the rules laid down for cardiac conditions 
in general would apply equally well to the senile heart, remem- 
bering that elderly people require actually less food than 
younger individuals, as their metabolism goes on at a so much 
lower rate. The necessity of a light evening meal should also 
be emphasized. 



DIET IN DISEASES OF THE BLOODVESSELS 277 



DIET IN DISEASES OF THE BLOODVESSELS. 

Arteriosclerosis. — When we come to consider the question 
of diet in arteriosclerosis we find almost everybody has some- 
thing to say, most of it based on individual clinical evidence 
( ?) and much on speculation. As a matter of fact Httle is 
known of the specific action of food-stuflFs on the various 
organs and whether this or that article of food causes or 
favors arteriosclerosis must yet be worked out experimentally 
in the biochemical laboratories. 

There seems, however, very direct evidence that persistent 
overeating in general is responsible for many cases and as we 
know experimentally that artificially raising the blood-pressure 
apparently causes arteriosclerosis (adrenalin injections in rab- 
bits), all foods which raise pressure presumably favor its pro- 
duction. Longcope^ showed that in animals repeated innocu- 
lations of protein (after having been sensitized by previous 
injection) produced in the organs changes analogous to those 
seen in general fibrosis, whether of vessels, heart, Hver, kid- 
ney, etc. This fact may have great bearing on the production 
of arterial changes. Clinically Bishop^ arrived at much the 
same conclusion, considering arteriosclerosis, chronic nephritis, 
cardiosclerosis, etc., to be caused by the pathological reac- 
tion between the animal cell and some particular protein 
ingested or derived from bacterial growth, to which the 
organism had been sensitized, analogous to anaphylaxis. To 
combat this he recommends a diet in which all animal protein 
but one is excluded; cheese is the one usually given first, then 
later adding other proteins one by one to see if any one causes 
symptoms. This he calls a "few protein" diet, and proteins 
are used qualitatively rather than quantitatively. Whether 
or not this is a correct assumption, it is at least in accord with 
what little scientific data we have and is certainly worth 
careful consideration. 

Von Noorden^ insists that there is no reason for leaving 
meat entirely out of the diet in arteriosclerosis, as we have 
proved nothing against meat as favoring its production. On 
the other hand, presumably anything which favors hyperten- 
sion favors arteriosclerosis and meat certainly, clinically, does 
increase blood-pressure when a large constituent of the diet. 
He does lay great stress on restriction of fermentable foods, 
heavy meals and more than a total of ij pints of fluid in 
the twenty-four hours, which alone he says often reduces 

^ Trans. Int. Med. Cong., London, 1913. 
2 Med. Record, 1913, Ixxxiv, 511. 
^ Post Graduate, 19 13, xxviii, 426. 



278 DISEASES OF THE CIRCULATORY ORGANS 

the pressure 20 to 40 mm. Hg. (See relation of obesity and 
reduction cures to hypertension.) 

Diet in Hypertension. — That which applies to arterio- 
sclerosis applies to hypertensive cases with apparently equal 
force, therefore it would seem wise to limit the amount of 
protein intake to the low level compatible with nitrogenous 
equilibrium, especially the purine bodies, as well as the limitation 
of quantity, calorically, to meet the needs of the patient as 
gauged by his various activities. The prevention of indican- 
urea is apparently of distinct advantage. Eustis^ observed 
that all ( ^ ) cases of high arterial tension were accompanied 
by indicanurea, relief of which, by giving a non-nitrogenous 
diet, was often prompt. The explanation of this is based on 
Bargers- finding parahydroxyphenylethylamine (a pressor 
substance) in the blood of such patients. This, with Dale 
and Dixon, he also isolated from the tyrosin of putrefactive 
meat, another similar substance was produced from leucin 
from putrid meat. 

Cornwall's^ rules for diet in hypertension probably repre- 
sent the consensus of medical opinion and might be formulated 
somewhat as follows: 

1. Keep the diet low in protein, 60 to 65 gm. per day, 
largely purine-free or with low percentage of extractives (soups 
and meat). 

2. Regulate the quantity to secure the minimum of work 
from the organs with maximum nutrition. The caloric value 
of which should vary from 1500 to 2000 to 3000 accordingly, 
as a patient is in bed, leading a sedentary life or working. 

3. Restrict the diet so as to meet indications presented by 
the kidneys, liver, heart and gastro-intestinal tract. 

4. The diet should be antiputrefactive, excluding fermentable 
carbohydrates and should be laxative as well. 

The Effect of Various Substances on Blood-pressure.— 
I. Food substances causing an increase of blood-pressure are 
principally the purine bodies in meat or meat soups, i. e., the 
extractives, for the lower the percentage of the latter in meats 
the less prone are they to increase blood-pressure. For this 
reason glandular organs are usually more likely to increase 
blood-pressure than other parts of the animal, and meat that 
is roasted or broiled has more effect than if boiled or, least of 
all, if boiled in two waters. Here too, food of almost any kind 
is much more apt to increase pressure if taken in large amounts, 
for, as already stated, overeating seems to be one of the chief 

^ Southern Med. Jour., 1912, v, 244. 
2 Trans. Eng. Chem. Soc., 1909, xcv. 
2 New York Med. Jour., 1912, xcvi, 315. 



DIET IN DISEASES OF THE BLOODVESSELS 279 

factors in the production of arteriosclerosis and hypertension. 
Alcohol in moderate dosage probably has Httle or no effect 
on blood-pressure — when taken more liberally it causes a fall 
in pressure. Excess of fluid in any form tends to increase 
pressure. 

2. Those foods which tend to decrease blood-pressure are 
the carbohydrate foods; farinaceous foods, vegetables, fruits, 
fats, and milk preparations, as the latter are purine-free. 

Aneurysm. — Aneurysm has also been the subject of special 
dietary attention, Tufnell prescribing the best-known regimen 
which is noted for its extreme restriction : Breakfast 2 ounces of 
bread and butter, 2 ounces of milk or cocoa. Noon, 3 or 4 ounces 
meat with 2 or 3 ounces of potato or bread and 3 or 4 ounces of 
water. Night, 2 ounces of bread and butter, 2 ounces of milk or 
tea. Of course this is an absurd diet and only a strong person 
could stand it at all; the resulting blood concentration which 
it is hoped to gain is more than off'set by the starvation neces- 
sary and would be distinctly bad for weak persons. All blood- 
pressure-raising foods should be avoided, however, as well as 
psychical irritation, intestinal fermentation and bodily over- 
work.^ 

Angina Pectoris. — Both the rules for avoiding the produc- 
tion of arteriosclerosis and hypertension should be made use 
of, special attention being given to the avoidance of acute 
attacks of indigestion which often accompany a fatal attack 
of angina, although many times indigestion is undoubtedly 
secondary to the claudication rather than the cause of the 
anginal attacks. The evening meal should be simple and light. 

Tobacco in Relation to Cardiac Disease. — While not a 
food, tobacco is so generally in use that a word as to its place 
in cardiovascular cases is not amiss. Not much is really 
known about the continued efi^ect of small doses of tobacco 
and its contained alkaloids, although there are many theories; 
there is, however, practical unanimity of opinion regarding its 
large or excessive use and that so used it is of distinct disad- 
vantage. By its blood-pressure-raising qualities, its prone- 
ness to disturb digestion in some persons, to cause irritation 
of the myocardium (extrasystoles) it is certainly best left 
alone in these conditions; whether a very moderate use of 
tobacco by its soothing and contenting effects may not offset 
the possible bad effect of continued small amounts is a ques- 
tion to be decided in each case. If a patient becomes suscep- 
tible to its effects or if used in large amounts, there is every 
reason for interdicting the use of this substance. 

1 Hccht Zwit. Fr. Med. Klin., 1912, Ixxvi, 87. 



CHAPTER XIX. 

FEEDING IN DISEASES OF THE LUNGS. 

Much of what has been said in regard to the relation of diet to 
diseases of the circulatory apparatus holds equally true of the 
pulmonary diseases. In addition, food must be considered in 
its relation to acute or chronic infections, and from the mechan- 
ical stand-point as a possible factor in increasing symptoms by 
pressure from an overloaded or distended stomach; besides, 
of course, its nutritional value. 

PNEUMONIA. 

In pneumonia, lobar or lobular, we are dealing for the most 
part with a self-limited disease of short duration, i. e., as 
compared with typhoid for example. On this account the 
food quantities that are given would perhaps not be so impor- 
tant if we could be sure a case would run for not more than 
seven to ten days. Unfortunately some of the cases run 
considerably longer or else develop serious complications, 
such as empyema, in which it is of the utmost importance 
that the patients should not have lost flesh and strength 
unnecessarily and so arrive at the late stages of the disease 
or its compHcations, in an overweakened condition. On this 
account the proper dietary treatment may have a very real 
bearing on the prognosis of the disease. 

The routine diet in these cases has usually been feeding of 
milk, broth, albumin water and gruels with a total nitrog- 
enous content and caloric value far below the body's require- 
ments. Coleman, on the other hand, has applied the principles 
of the high caloric diet as used in typhoid and apparently with 
some success, but the need for the prevention of abdominal 
distention makes the giving of large quantities of food, espe- 
cially carbohydrates, questionable, and as the majority of 
cases run but a week, it is perhaps wisest to be content with 
nourishing patients, if not to the full limit of a theoretical 
capacity, at least sufficiently to prevent undue losses. 

The necessity for keeping the excretory organs unhampered 
by excessive amounts of the products of food metabolism must 
also be kept in mind, for at times it seems as if we could ask 



PNEUMONIA 281 

little more than that the organs should remove the disease 
toxins as rapidly as they are formed. It is nevertheless most 
important that sufficient food of the right sort should be given 
in order that the natural antitoxin-producing organs should 
run at their highest efficiency, under the circumstances, and 
as well, to prevent a starvation acidosis from further compli- 
cating the picture. We know, too, that in pneumonia the 
percentage of uric acid in the blood is always higher than 
normal, due to an excessive endogenous uric acid metabolism, 
and one should therefore avoid as much as possible feeding 
the purine bodies in the food. These two indications are met 
by giving a fair but not excessive amount of carbohydrate and 
fats and a low purine or nearly purine-free diet, during the 
acute stage of the illness, all in a liquid or semisolid form. 

To adults accustomed to their cup of tea or coffee in the 
morning, this should be continued, but not in large amount, 
for Mosenthal has shown that the giving of caffeine to an 
already inflamed and overburdened kidney sometimes brings 
disaster. The broths and meat extracts and jellies are best 
left out of the dietary, as they contain only infinitesimal 
amounts of food and a high percentage of purine bodies. There 
is one legitimate use of meat extracts or broths in small 
amounts, namely, when anorexia is present a small cup of 
well-seasoned, broth does more to cheer up a forlorn appetite 
than anything else. The diets No. i and No. 2 as outhned for 
typhoid fever, represents a very good assortment of foods, 
leaving out the broth where indicated, also omitting some of 
the lactose if there is any indication of tympanites. A good 
diet for an average-sized person might be formulated somewhat 
as follows: 

8.00A.M. Milk and coffee, each 120 c.c. (4 oz.), 240 c.c. 

(8 oz.); sugar. 
10.00 A.M. Milk in any form, hot or cold, 240 c.c. (8 oz.). 
12.00 M. Gruel, 120 c.c. (4 oz.), with milk 180 c.c. (6oz.). 

2.00 P.M. Milk feeding, as at 10.00 a.m., 240 c.c. (8 oz.). 

4.00 P.M. Gruel, 120 c.c. (4 oz.), with milk, 180 c.c. 
(60Z.). ^ 

6.00 P.M. Custard with lactose (4 oz.), i cup. 

8.00 P.M. Milk feeding, as at 10.00 a.m., 240 c.c. (8 oz.). 
10.00 P.M. Whey, 180 c.c. (6 oz.), with one whole egg and 

sherry, 15 c.c. (J oz.) 
12.00 P.M. Gruel, as at 12.00 o'clock noon. 

2.00 A.M. Milk as at 10.00 a.m. 

4.00 A.M. Whey, 180 c.c. (6 oz.), or hot milk 240 c.c. 
(8 oz.). 

6.00 A.M. Milk, as at 10.00 a.m. 



282 FEEDING IN DISEASES OF THE LUNGS 

Approximate values: 

Protein, 90; fat, 91; carbohydrate, 220 gm.; calories, 1825. 

The value of this diet can be considerably increased by add- 
ing 500 c.c. (i pint) of cream if divided between each 
milk or gruel feeding, which would make the total values, 
protein 103, fat 180, carbohydrate 235, and calories 2800. 

Since sleep is of the utmost importance in pneumonia, a 
rest from feedings at night of from six to eight hours is advis- 
able if the patients will sleep, but they are to be fed when 
awake not oftener than every two hours. With the onset of 
tympanites feedings must be stopped for a few hours so that 
the beneficial effects of stupes to the abdomen and a hypo- 
dermic of pituitary extract, etc., may be obtained. When feed- 
ings are resumed it is often better to leave sugar and milk out 
of the diet unless the latter is fully peptonized (2 hours) or 
else given in some other form than raw milk. The use of other 
artificial digestants is often of service. 

In this connection it seems worth calling attention to the 
use of a good Bulgarian bacillus culture given in a little sweet- 
ened water three times a day on an empty stomach. The 
apparent effect of this is often most happy in reducing the 
distention, as is also indicated in the discussion of typhoid 
fever. 

The feeding of cases of pneumonia complicated by nephritis 
will depend upon the severity of the latter disease but the 
aforementioned diet usually serves well, although it is often 
wise to have it prepared without salt. 

Drinks. — In addition to large amounts of plain water (pro- 
vided the circulatory apparatus is in order), patients are 
usually grateful for fruit juices with water, such as lemonade, 
orangeade, grape juice, etc. When the ordinary foods are 
taken poorly a 5 per cent, solution of gelatin flavored with 
one of these juices makes it possible to supply a good deal of 
nourishment, almost without the patients realizing that the}^ 
are taking anything but flavored water. 

When the temperature falls and the symptoms of toxemia 
are past, a gradual return to a more normal diet may be begun, 
first by using soft diet, later adding meat and vegetables as 
convalescence proceeds. A thorough emptying of the intestine 
by a cathartic, after the temperature is normal, is an invaluable 
aid to the digestion and helps the appetite to return. 

BRONCHITIS. 

Acute Bronchitis. — In adults, this is a condition sui gmerisy 
or a result of infection, possibly also due to sudden climatic 



MONCHITIS ^83 

changes, although this latter is presumably only predisposing. 
Then, too, there are the complicating cases of acute bronchitis 
occurring in the course of almost all the infectious diseases, 
such as pneumonia, typhoid fever, measles, etc. 

In certain elderly people acute bronchitis is a local manifes- 
tation of some general diathesis, e. g.y gout, nephritis, and in 
these cases certain dietetic regulations referable to the under- 
lying cause must be taken into consideration and the diet 
made to harmonize with it. Again in other cases it is a matter 
of general undernutrition and the bronchitis continues to recur 
indefinitely until the organism is put in fighting trim by forced 
feeding and all measures to raise the physical resistance, fresh 
air, exercise and general hygeine. 

When fever is present the di^t should consist of Hquid and 
soft solid foods, milk, cream, cereals, fruit juices, egg, creamed 
toast, bread, butter, coffee, cocoa, weak tea, mineral water 
and a large amount of any good drinking water. 

The appetite must be consulted and as this is often very 
poor, the patients for the first day or two frequently wish for 
nothing but cold liquids of one or another sort. If the intes- 
tinal canal has been thoroughly emptied at the outset, the 
appetite frequently improves, and it is then more easily pos- 
sible to increase the food. Whenever possible it is always 
advisable to feed these patients up to the limit of their diges- 
tive capacity as it shortens convalescence and Coleman and 
Shaffer have found in their typhoid diet investigation that 
even a high degree of body temperature is not incompatible 
with liberal feeding, as the average patient is able to digest 
and metabohze food practically as well as in health, provided 
the proper foods are used. 

As soon as the patient wants solid food it may be given, 
omitting only the well-known indigestibles and much meat. 

Chronic Bronchitis. — Chronic bronchitis is frequently a 
condition accompanying chronic emphysema, and when so 
present is to be dieted in accordance with the suggestions 
detailed for that disease. In many cases it is the initial feature 
of asthma and as such is in need of an etiological diagnosis, 
when possible, in order to prescribe diet on any satisfactory 
basis. Thus we may find it a local expression of a general 
erythema, urticaria or anaphylactic reaction to foreign pro- 
tein; or a reaction to some form of endogenous toxicosis, gout 
or uremia; a complication of pulmonary tuberculosis or a 
reflex from some distant organ. Where any one of these causal 
conditions are found, the diet appropriate for the underlying 
condition must be made use of. If, however, none of these 
factors can be found as responsible for the trouble, the only 



284 FEEDING IN DISEASES OF THE LUNGS 

possible method is to proceed on empiric lines and frame the 
diet with a view to the least disturbance of digestion, both from 
the direct digestive point of view and the avoidance of mechan- 
ical factors which would work adversely in causing precordial 
pressure and embarrassment of respiration. 

Foods to Avoid. — Keeping in mind both these possibilities, 
we must avoid ordering foods in themselves indigestible, or 
which are easily fermentable, such as members of the cabbage 
family; cauliflower, cabbage, Brussels sprouts, and heavy 
sweets. 

Foods Suitable in Chronic Bronchitis. — All simple foods, sim- 
ply prepared, keeping down the amount of protein food, espe- 
cially in elderly people; fat foods such as cream, butter, fat 
meat, etc., enjoy a favorable reputation in all chronic pul- 
monary affections and should be freely used. Laxative foods, 
such as fruits, green vegetables and simple salads should form 
a considerable element in the diet, as excretion is to be pro- 
moted in every direction and a clear colon is of especial impor- 
tance, for an acute exacerbation of the bronchitis is often 
traced to an increase in constipation. Water drinking, up to 
six to eight glasses a day should be insisted on, either as plain 
water or in the presence of any considerable degree of urinary 
acidity, partly as mineral alkaline water. 

EMPHYSEMA. 

Emphysema being for the most part a presenile change and 
usually accompanied by a general sclerosis of the other organs 
and bloodvessels, its dietetic treatment resolves itself princi- 
pally into the dietetics of the concomitant conditions, such as 
bronchitis, chronic nephritis and arteriosclerosis. 

The food should be simple, easily digestible and not apt to 
cause flatulence; the sugars and starches should on the latter 
account be largely restricted. In fact any embarrassment of 
the circulation by abdominal distention may easily prove 
serious, particularly in the presence of marked arterial changes. 
There is no way of directly influencing the emph3^sema except 
by promoting the general health by means of careful attention 
to the details of eating, not alone in the character of the foods 
ingested, but the method of eating plays a considerable part 
in the care that can be given these people. 

In the first place great care should be taken not to overeat, 
not alone on account of the possible mechanical factors but 
because the waste products of digestion play such a part in 
the increase of symptoms due to the complicating conditions 
already enumerated. On the same account elimination should 



ASTHMA 285 

be promoted in every way and often the discomforts of diges- 
tive disturbances of all sorts are minimized by this means. 
It would seem as if Fletcher's principles of eating might afford 
great reUef from the annoying complications, reducing as it 
does, the protein ration to the low level of physiological 
economy in nutrition and rendering the methods of forced 
elimination almost unnecessary, as there is the minimum of 
waste matter to be gotten rid of (see Fletcherism, p. 590). 
Whether one follows this philosophy or not there is unques- 
tionable virtue in keeping the intake of protein low and ren- 
dering combustion and ehmination of food products as com- 
plete as possible. 

ASTHMA. 

As asthma is but a symptom of disturbance either primarily 
in the bronchial tree or remote in other organs, the first step 
in ordering a diet must be to determine what the underlying 
pathological condition is. If it is due to a bronchitis, to a 
toxicosis as in nephritis or from gastro-intestinal disease, relief 
must be sought in the correction of the abnormal conditions 
including the diet suitable for each {q. v.). Formerly asthma 
was thought to be due to many nervous influences acting in a 
reflex manner, and while this may be true in a certain small 
proportion of the cases, it is by no means proved. A true 
explanation of many of the hitherto obscure cases is found in 
the phenomenon of anaphylaxis due to the effect of a foreign 
protein on an organism already sensitized to that protein. 
This is seen in hay fever very frequently and from dietary 
indiscretions where persons with a known idiosyncrasy to egg 
white, for example, develop an attack of asthma after eating 
some dish made with egg. Where the cause is known or easily 
found, the diet may be readily adjusted. But there remains 
a large number of cases of asthma which cannot easily be 
etiologically classified — in these persons it is often helpful to 
test out the skin reaction to different proteins in the food, and 
where a protein is found to give a positive skin reaction it 
should be eHminated from the diet. After such a change in 
diet it is necessary to persist in it for at least ten to fourteen 
days, until all that particular protein from previous ingestion 
is eHminated, before it is possible to decide whether the 
suspected protein is responsible for the attacks of asthma or 
not. 

When it is not possible by any method to come to a definite 
conclusion as to the cause of the asthma in a particular case, 
it is necessary to order diet on purely empirical lines, keeping 
in mind the following points: 



286 FEEDING IN DISEASES OF THE LUNGS 

1. Indigestion, either gastric or intestinal, should be avoided 
by ordering only simple food simply prepared. 

2. The diet should be laxative as far as possible, as intes- 
tinal torpor in all its forms distinctly predisposes to the 
production of asthmatic attacks. 

3. It is probable that in many cases of unknown origin some 
one or other of the proteins is at fault, most often perhaps an 
animal protein. On this account it is often useful to curtail 
the amount of protein ingested, keeping the total daily intake 
down to the lower limits of physiological economy in nutri- 
tion, as suggested by Chittenden. Another reason why this 
is often helpful is, that, in many of the older or long standing 
cases, renal excretion is deficient and with nitrogen retention, 
symptoms of toxemia often develop. 

4. Where the asthma is nocturnal, the evening meal should 
be exceedingly sparing and nothing allowed which by its bulk 
or from fermentation would add an element of embarrassment 
to the circulation or the lungs, by pressure upon the thoracic 
organs. 

5. Patients with asthma should take sufficient mild exercise 
to assist in the complete burning of the food-stuff's, leaving as 
little residue, either intestinal or systemic, as possible. 

6. Most of these patients are helped by drinking a fair 
amount of water, particularly between meals, and night and 
morning- — six to eight glasses. With these suggestions in mind 
it should be a simple matter to order foods which meet the neces- 
sary conditions so far as it is possible to know them. 

Foods to Avoid. — Much sweet food, or heavy sweets of all 
kinds — syrups, candy, layer cake and preserves. Readily fer- 
mentable vegetables, such as cauKflower, cabbage, Brussels 
sprouts, much onion or potato. Alcohol, except in the most 
sparing amount and then only for some special indication. 
Indigestible meats as: goose, duck, veal (unless very tender) 
and fresh pork. Tobacco should be used sparingly, if at all. 

What has been said in regard to diet in asthma holds equally 
true for cases of urticaria, which is usually, if not always, an 
anaphylactic skin reaction. 

PLEURISY WITH EFFUSION. HYDROTHORAX. 

In both of these conditions there is fluid in the pleural sac. 
In the case of a pleurisy it comes as a product of inflammation, 
in hydrothorax it is merely a transudation, principally from 
stasis. 

In the early stages of pleurisy if there is fever the patient 
must be fed as for any fever. When the exudate is established 



EMPYEMA 287 

and the patients afibrile an attempt may be made to regulate 
the diet so as to assist in the removal of the fluid, for although 
not successful in the case of large exudates, small ones may be 
absorbed, often without recourse to tapping. To this end the 
two chief indications are to curtail the water intake to 800 to 
ICXDO c.c. and exclude salt from the diet by the use of one of 
the salt-poor diets. (See Nephritis.) 

It must be remembered in employing these diets that fre- 
quently little result, so far as diminishing fluid or edema, occurs 
during the first few days, then, when the sodium chloride 
reserve is considerably diminished, the free excretion of the 
fluids often begins. 

The dietetic treatment of hydrothorax depends more or less 
upon the underlying condition which is the cause of the fluid 
accumulation, e. g., nephritis and cardiac decompensation. In 
either condition the same regimen as prescribed for pleuritic 
eff^usion is indicated, viz., limitation of fluids and a salt-poor 
diet, the details of either being dependent on the form of the 
nephritis or the degree of decompensation. 

EMPYEMA. 

Empyema whether due to invasion of the pleural sac by one 
of the ordinary pus organisms or whether the original infec- 
tion is tuberculous with a secondary infection added, the 
dietetic indications are the same. The formation of pus, par- 
ticularly in such great quantities as takes place in empyema, 
takes a large amount of fat from the body, as the percentage 
of fat in pus is exceedingly high. On this account it is neces- 
sary to feed in large amounts as well as to prevent undue 
loss of body weight. If the fever is high it will be necessary 
to modify the usual diet in accordance with the principles of 
fever requirements both in quantity and quality, but the fact 
must not be forgotten that if we are to hope for any success 
in our treatment the chief requisite is a body nourished up to 
the height of its capacity. 

To this end it is essential that a careful record be kept and 
the caloric value of the food estimated, for it is likely that if 
the patient's appetite is allowed to dictate the terms of the 
menu the total energy value of the food will be too low. If 
the appetite is poor, remember that milk either alone or modi- 
fied upward by the addition of cream and lactose (see Typhoid 
Fever) can practically always be digested, even in the absence 
of appetite, provided too high a formula is not used. If the 
appetite is fair or good, then one must go ahead and feed 
liberally all digestible and nourishing foods, making sure that 



288 FEEDING IN DISEASES OF THE LUNGS 

the proportion of fat in the diet is high by giving cream, 
250 to 500 c.c, i or I pint per day, butter up to 250 gm. 
(J pound), or as nearly that amount as will agree with the 
patient; for the rest the appetite may be trusted largely to 
determine the choice of foods. 

If the case is tuberculous in origin the diets as recommended 
for tuberculosis will be found useful. In either case great 
attention should be paid to the digestion to make sure that 
through Hght exercise or massage the muscular system is kept 
in condition. 



TUBERCULOSIS, PULMONARY OR GENERAL. 

In none of the infectious diseases is a proper dietary of so 
great importance as it is in tuberculosis; one has only to think 
of its older name *' consumption" to realize the truth of this 
statement; and whether the disease is seen in its acute or 
chronic form, pulmonary or other distribution, the necessity 
for a definite feeding plan is paramount. There can be no 
possible doubt that food, good food, properly chosen, properly 
prepared and eaten in cheerful surroundings is our sheet- 
anchor in this disease. So much has been written in all lan- 
guages in regard to this, that it hardly seems necessary to 
dwell upon it, but apparently many practitioners either do 
not appreciate these facts or are too easy going to take them 
seriously and valuable time is lost, to say nothing of the 
patient's weight. 

Among the earliest symptoms of tuberculosis, the various 
disturbances of digestion rank a good second in importance, 
as many of the incipient cases first complain of gastro-intes- 
tinal symptoms, such as gas, heaviness after meals and often 
sour stomach. Jacob^ who examined the gastric contents, after 
test meals, in 50 cases, found hyperacidity or normal acidity 
the rule in incipient cases, and that the symptoms complained 
of were often similar to those of organic gastric lesions. He 
also concluded that the secretion of hydrochloric acid in fever 
was quite independent of the height of the temperature. 

By the older method of stufl&ng these patients with food, 
particularly in using large amounts of milk, the patients often 
developed the symptoms of gastric atony and many cases 
returned from sanitoria with a well-marked atony, due of 
course, to the very real weakness of the gastric muscle which 
was part of the general asthenia, but immensely exaggerated 
by overfeeding. Fortunately this mistake is now more rarely 

^ New York Med. Jour., 1913, xcvii, 297. 



TUBERCULOSIS, PULMONARY OR GENERAL 289 

seen, particularly where any sort of intelligent care has been 
exercised in the selection of a diet. What, then, should be the 
general principles upon which a suitable diet may be con- 
structed? To this question one will find many answers. Some 
advocating high protein diets, others high fats and still others 
a diet high in both of these elements. 

First, the question of what should be the object sought m 
diet, may well be asked. There is now unanimity in the 
belief that a great gain in weight above the normal for the 
individual should not be sought and a weight of not over five 
to ten pounds overweight represents the optimum. Too much 
weight increases the work of the other organs and hampers 
the heart and lungs. When this has been gained Brown's^ 
advice is certainly founded on experience and common sense, 
when he advises patients to eat just enough to maintain this 
increase, avoiding milk. The Httle flare-ups and upsets in the 
course of the disease which cause loss of weight will come, and 
he then advises patients to take milk in addition to their 
regular diet until this weight is regained, then to drop it. 
(The use of milk will be further discussed later on.) 

The amount of protein proper for the tuberculous to eat has 
been the subject of much comment and discussion, one set of 
cHnicians insisting that a considerable increase in this should 
be the rule, particularly as appHed to animal protein, and 
Watson^ estimates that this diet should be one-third more 
nutritive for the tuberculous than for the non-tuberculous. 
This increase he applies to proteins and fats but not to carbo- 
hydrates on account of their tendency to ferment. In recom- 
mending this increase in animal protein he refers to experi- 
ments proving that meat in uncooked form is especially bene- 
ficial, the effect being from the juices of the meat rather than 
the fiber, and that in some way the thyroid is favorably influ- 
enced by uncooked meat, eggs and milk. He probably has in 
mind, Cornil and Chautemesse's experiments in which they 
found that dogs fed on raw meat resistedartificial tuberculous 
infection better than those fed upon cooked meat. 

Kendall,^ on the other hand, is against an excessive protein 
feeding on account of the extra work thrown on the kidneys 
in excretion, and quotes Bardswell and Chapman who thought 
that ** patients made less satisfactory progress on diets of very 
large nutritive value than when of smaller value and any 
considerable increase in the amount of protein in the diet 
produced a disproportionate excretion of nitrogen, an increase 

^ Canada Pract. Rev., 191 2, xxxviii, 529. 

2 Practitioner, 1913, xc, 102. 

3 Canada Med. Assn. Jour., 191 2, p. 670, 

19 



290 FEEDING IN DISEASES OF THE LUNGS 

in the amount of imperfectly oxidized proteins in the urine, a 
decrease in the percentage of nitrogen absorbed and an 
increase in the amount of aromatic sulphates excreted, indi- 
cating increased intestinal putrefaction." Certain it is that 
we wish to keep the patient in at least full nitrogenous equi- 
librium, and while this can be worked out with scientific 
accuracy in a fully equipped sanitarium or hospital where 
nitrogen estimations can be made of intake and output, such a 
procedure is outside the range of possibility in ordinary practice. 
In planning the ideal diet for the tuberculous, one must 
take into consideration several factors. The question whether 
the patient has fever or not, whether it is necessary to con- 
tinue at work or whether freedom from care and work can be 
assured, for naturally the fever patient or one who is obliged 
to work needs more food than another, and individual judg- 
ment on the part of the physician must be used; but for the 
ordinary resting case, protein 80 to 100 gm., fats 80 to 100 gm., 
carbohydrates 300 to 350 gm. would represent a good aver- 
age, giving a total caloric value of 2500 to 3000 calories. 
These, as in the case of other diets, can be worked out from 
the table of lOO-calorie portions. 

As an example of the high protein diet we have the follow- 
ing published by Watson^ which he especially recommends. 
No. I is largely a milk diet. No. 2, largely a meat diet. 

Diets in Tuberculosis: 
No. I ^ 

7.00 A.M. Milk, J pint (250 c.c). 

8.30 A.M. Milk, i pint (250 c.c.) with casein J ounce 
(15 gm.), flavored with coff'ee or cocoa; gruel, 
made with milk and flavored with cream. 
11.00 A.M. Soup, thickened with i pound (120 gm.) raw 
scraped beef; or soup thickened with an egg 
and cream or milk with egg. 
1. 00 P.M. Chicken essence or veal jelly, strengthened with 
casein J ounce (15 gm.) and milk i pint 
(250 c.c); or raw meat minced J pound, with 
milk; or raw meat rissoles, with milk or raw 
meat sandwiches with milk. 
3.00 P.M. Milk with egg or thin custard. 
5.00 P.M. Milk tea, | pint (250 c.c ) with cream. 
7.00 P.M. Meat juice, e. g., Wyeth's, Leube-Rosenthal's 
meat solutions mixed with port or Burgundy; 
or soup with raw meat, or beef extract with 
egg and milk forming a custard; or milk and 
arrow root, with casein and cream, h pint 
(250 c.c); (brandy ma}^ be added). 

^ Practitioner, 1913, xc, 102. 



TUBERCULOSIS, PULMONARY OR GENERAL 291 

8.00 P.M. An invalid food made with milk, J pint (250 c.c), 
and casein. 
11.00 P.M. Milk and egg or chicken broth and egg. 

In severe cases, milk may be taken peptonized or fermented, 
e. g.y kumyss, zoolak; buttermilk or ripened milk (Bulgarian 
bacillus) may agree better. 

No. 2. A diet largely meat, often helpful when dyspepsia 
follows large meals. 

6.00 A.M. Milk, J pint (250 c.c). 

8.00 A.M. Milk, J pint, with casein J ounce (15 gm.), 
flavored with coffee, or cocoa and peptonized; 
slice of toast with butter; bacon, ham, eggs, 
fish, meat rissoles or steak (taking two 
things). 
11.00 A.M. Glass of hot milk with eggs, or raw meat soup. 
1. 00 P.M. Luncheon — soup from strong stock, or fish soup 
or a helping of fish; mince, lightly grilled ten- 
der steak or chop, or slice of underdone sir- 
loin of beef, or roasted leg of mutton; stewed 
fruit and custard or jelly with cream; toast, 
glass of milk. 
4.00 P.M. Cup of milk, tea, toast, butter, or biscuit and 

butter. 
7.00 P.M. Dinner — same as luncheon; a little wine. 
Prophylaxis for Children of Tuberculous Inheritance.^ 
When one has to do with children of tuberculous parents or 
those who are more or less constantly exposed to this infection; 
the necessity for a proper feeding plan is self-evident. Espe- 
cial attention should be given to following the weight of the 
child from month to month so that the first sign of loss or 
even of failure to gain may be noted. The food should be espe- 
cially nourishing and all other foods eliminated from the diet 
as much as possible. Particular hygienic care should be exer- 
cised in the daily routine and everything done in diet, work, 
play, sleep and fresh air to promote the greatest degree of 
physical efficiency. 

Plan of Feeding. — When a patient is able to take ordinary 
full diet the best plan is to give only three meals a day, pro- 
vided of course, the patient can eat sufficient at a meal to 
produce the required gain or to maintain an increase already 
accomplished. When a patient cannot attain this result on 
three meals alone, it is best to try between-meal lunches of 
reinforced milk, sandwiches, etc. Still other patients, of 
course, can eat only smaller amounts at a time and here the 
feedings must be more frequent, but if possible, three or four 



292 FEEDING IN DISEASES OF THE LUNGS 

hours should elapse between them, using the two-hour inter- 
val only if necessary and taking care not to overcrowd a 
gastric muscle which may be already losing its tone. 

When the stomach is very irritable, any of the feedings 
referred to under gastric irritability may be used for this 
condition, or even gavage if necessary, as this often results 
in more food being retained than when given by mouth. 

Special Foods for the Tuberculous.— Milk. — Milk has from 
time immemorial, held the first place as an extra in the diet 
of these cases, but of late years a certain prejudice has arisen, 
particularly against its large use. The reasons for this have 
already been intimated in that it takes an excessive amount 
of milk, if one attempts to feed milk alone, which overdistends 
the stomach, often resulting in atony, so that many clinicians 
have discarded its use entirely, while others use it for certain 
indications in very moderate amounts. The exclusion of milk 
from the dietary is no more sensible than its excessive use, 
but the indications for it may be perfectly definite and it 
then is, of course, most useful, e. g., to add an extra to the diet 
in cases of failing nutrition; when people are especially fond 
of milk and in irritable conditions of the gastro-intestinal 
tract. In the latter, especially for cases with nausea, vomit- 
ing, diarrhea or fermentation; buttermilk or artificially ripened 
milk, keffir, zoolak, etc., may be used to the greatest advan- 
tage. A very good way in these cases is to feed one of these 
prepared milks every two hours and with every other feeding 
to add some soft solid. 

Eggs. — Another form of food long popular in the treatment 
of tuberculosis, eggs still hold a prominent place in its dietary, 
but in the hght of present-day physiological chemistry, eggs 
must be used as a very potent albuminous and fat food and 
enter into calculations of the diet as such, not to be taken 
indiscriminately in massive daily quantities in addition to 
regular meals, on the assumption that the more food the better 
for the tuberculous patient. Incidentally, slightly cooked eggs 
are better and more completely digested than raw eggs, since 
the raw albuminous portion is often hardly digested at all, as 
shown by examination of the stools. 

Fats. — These hold a high place in the diet, for they are 
non-fermentable and their excretion does not tax the kidneys, 
being oxidized into water and COo. Animal fats being more 
nearly homologous are probably better than vegetable oils, 
and the fat from cod Hvers stands at the head of the list; for 
certainly this fat furnishes something which is in addition to 
its hydrocarbon content. Possibly it is its iodine and possi- 
bly something belonging to that Httle-understood class of food- 



TUBERCULOSIS, PULMONARY OR GENERAL 293 

stuffs called vitamines, but at all events clinically it does more 
for the patient than oth-er fats do. To be sure, this can be 
taken only in limited quantities and the bulk of the fat in the 
diet must be made up of meat fat, butter, eggs and cream. 
The latter should alwa3^s be taken fresh and not altered by 
pasteurization or sterilization. This apphes to milk as 
well. 

The working standard for a diet in tuberculosis, according 
to King,^ must take into consideration the following factors: 

*' {a) Men of the same respective age and weight seem to 
require a larger diet than do women. 

"(/?) All other conditions being equal, a larger diet is appar- 
ently required by persons under thirty years of age than is 
the case after that period. 

" (c) The laboring class, i. e., those who earn their Kving 
by muscular work require more food than is the case with 
those living a more sedentary life, and in a certain measure 
the dietetic habits necessitated in the first place by occupation 
persist after occupation distinctions are removed. 

"(^) The urban dweller consumes a larger relative amount 
erf animal food and therefore derives a larger percentage of 
his energy from the protein constituent of his diet than is the 
case with the country dweller. This, of course, applies only 
to the higher orders of civilization." 

King then goes on to say, with these points in view and also 
keeping in mind individual variations, we may assume the 
following standards for ambulant cases of comparatively quies- 
cent tuberculosis under sanitarium treatment: 

"(i) For young adult men of the Vorking class' on very 
light exercise from 2800 to 3200 calories, of which from no 
grams to 125 grams shall be protein. 

" (2) For the same class on five or six hours' vigorous exer- 
cise (sawing or chopping wood, working with shovels, pick- 
axes, barrows, etc.), from 3100 to 3600 galories, of which 125 
grams to 140 grams shall be protein. 

"(3) For women of this class 200 calories and approxi- 
mately 10 grams protein may be deducted in each case. 

"(4) For young adult men, whose occupation has been more 
sedentary — e. g., clerks, bookkeepers, tailors, students, etc., on 
moderate exercise (walking from one to three hours daily) — 
2600 to 3000 calories, of which not over 115 grams need be 
protein. 

"(5) For women of this class not to exceed 2500 calories and 
100 grams protein. 

^ Med. Rec, 1909, October i6. 



294 FEEDING IN DISEASES OF THE LUNGS 

" (6) For older patients, a slight reduction in caloric value 
and a considerably lower protein constituent are desirable in 
each case. 

" (7) For the country dweller a somewhat larger bulk, with- 
out increase in protein value is usually desirable, all other 
conditions being similar, than is the case with the patient from 
the city." 

Kingi then reports interesting experiences with diets in the 
Loomis Sanitarium. In 1905 the ration was about as follows: 
Protein 166 gm. (5J oz.), fat 214 gm. (7 oz.), carbohydrate 
323 gm. (loj oz.), calories 3955. While on this the patients 
seemed to thrive and gain, but digestive disturbances were 
common. The following year the standard diet was changed 
to protein 131 gm. (4I oz.), fat 113 gm. (3I oz.), carbohydrate 
385 gm. (i2f oz.), calories 3166. On this diet the gains in 
weight were equally satisfactory and there were very few 
digestive disturbances. It was also found that those patients 
who were able to work consumed more food and had a better 
digestion than those who did not or could not. The compari- 
son of these diet values with those worked out by Bardswell 
and Chapman is as follows: 

Former Loomis Later Loomis 

Bardswell and Chapman. Annex standard. Annex standard. 

Protein . 150 gm. Protein . . 166 gm. . Protein . , 130 gm. 
Total calories 3200 Total calories 3667 Calories . 3200 

While the caloric value of Bardswell and Chapman is the same 
as the later Loomis standard. King felt that the lower protein 
allowance was a distinct advantage on account of {a) economy, 
{h) increased efficiency, (c) better digestion. 

Complications. — In pregnancy, compKcated by tuberculosis, 
the diet should receive special care and on account of a ten- 
dency to decalcification, said by some to exist,^ some form of 
lime should be freely supplied in milk, gelatin or even as cal- 
cium lactate in regular daily amounts. This question of 
decalcification is still unsettled so far as the biochemists are 
concerned, but until it is positively determined it would be 
the wiser error to give calcium to these cases in some form. 
The diet should also contain more protein than at other times. 

Diabetes, from a diatetic point of view, is one of the most 
difficult complications of tuberculosis to treat. This is not 
an infrequent association and certainly taxes the ingenuit}^ of 
the physician to the utmost. The associated hyperglycemia 
apparently favors the further development of the tubercle 

^ Diets in Tuberculosis. 

2 Dreman: Am. Jour. Obstet., 1913, Ixxvii, 893. 



TUBERCULOSIS, PULMONARY OR GENERAL 295 

bacillus and yet a marked reduction in carbohydrates is not 
always easy to obtain. The rules laid down for diabetes must 
be followed and an attempt made by increasing the proteins 
and fats to keep the body weight up to normal and of course 
under these circumstances the kidneys cannot be spared, as 
they must be called on to excrete the excess nitrogen. 

General Rules for Feeding in Tuberculosis. — An epitomized 
statement for diet in tuberculosis might be put somewhat as 
follows : 

1. Forced feeding is not necessary. 

2. Milk and eggs are to be used strictly with respect to their 
food values. 

3. A protein content of the food which furnishes a little in 
excess of ordinary requirements is best. 

4. Fats are especially useful. 

5. Three meals alone or three meals with three small lunches 
between and at bedtime offers the best distribution of meals. 

6. Avoidance of very bulky or fermentable foods should be 
insisted on. 

7. After normal weight or a weight slightly in excess of 
normal is reached, as Httle food should be taken as will main- 
tain this weight. 

8. Food should be eaten slowly under the most agreeable 
circumstances possible. 



CHAPTER XX. 
DIET IN DISEASES OF THE STOMACH. 

The most important factor in the treatment of diseases of 
the digestive system is, of course, proper food, as this far out- 
weighs everything else; medicine and mechanical treatment 
taking an inferior position. The selection of a proper diet for 
these diseases depends upon a number of things which must 
be taken strictly into account if one wishes to obtain anything 
Hke satisfactory results. 

Where the trouble is in the esophagus, one has to meet the 
conditions of stricture, dilatation or ulceration, either singly 
or combined. In gastric disturbances we have, speaking 
broadly, conditions of hyperacidity, hypoacidity, disturbed 
motiHty, narrowing at the pylorus, dilatation, and inflammatory 
conditions ranging from the simplest catarrhal inflammation to 
severe ulceration or cancer. 

In the intestinal canal we must reckon with inflammatory 
conditions, narrowing, dilatation, disturbances of secretion or 
motiHty, or any combination of these. Besides the elements 
already enumerated there must be considered the integrity of 
the accessory digestive glands, such as the liver and pancreas. 
Hence it can be seen at a glance how many possibilities must 
be considered in choosing a rational diet for disease in any 
part of the gastro-intestinal tract. 

Among the most important factors that must be taken into 
account are the influences exerted upon gastric secretion by 
various agents. In general these may be classed as either 
excitants to gastric secretion or depressants. Among the 
former may be included, acids, spices, condiments, water, 
alcohol, rough foods, proteins with high percentage of extrac- 
tives, concentrated sugar solutions. Among the depressants, 
fats (if they are bland) and alkalis are most important. Nervous 
influences, either reflex or psychic, act either as excitants or 
depressants to gastric secretion. 

In no other class of diseases is the personal factor so great 
as in digestive disturbances, for foods which may be per- 
fectly digested by a patient in health may not be in illness, 
so that one is constantly forced to vary the diet, not only for 
the diflferent phases of these digestive troubles, but for each 
individual and the individual variations in each patient. 



INDIGESTION 297 

There is however, immense satisfaction in the careful diet- 
ing of gastro-intestinal cases, for in no' other diseases is the 
proper diet more salutary than in these, save alone possibly 
some of the diseases of metabolism, notably diabetes. 



INDIGESTION* 

The proper digestion of food is such a complex matter that 
when one speaks of "indigestion" an endless variety of condi- 
tions naturally come to mind. Some of these are directly 
connected with the digestive processes and one may expect 
to get symptoms of so-called *' indigestion'' of an acute or 
chronic nature when any one of the digestive organs are 
involved in some form of derangement, and as well, the acces- 
sory digestive glands. On the other hand, one can have the 
most violent and persistent forms of indigestion referred to 
the stomach, whose origin is almost at the other end of the 
digestive tube; witness the effects on gastric digestion of a 
chronically diseased appendix, nephrolithiasis, cholelithiasis, 
adhesions, bands, etc., which may all result in digestive symp- 
toms and which the patient refers to the stomach. It is in 
many ways unfortunate that the stomach seems to be the 
mirror for the whole abdominal cavity and almost everything 
that happens within the abdomen, particularly when of a 
severe nature, has its gastric reflex, and the stomach, itself to 
blame for a sufficient amount of trouble, has been obliged to 
carry the opprobrium for digestive troubles which have their 
origin elsewhere. Then, too, when one uses the word "indi- 
gestion" one thinks at once of the gastric and intestinal vari- 
ety, so that it is necessary, so far as possible, to fix the blame 
where it belongs and use a term as broad as this with caution, 
properly hedged with a definite statement as to the organ at 
fault. Almost every form of pathological, anatomical or func- 
tional disturbance affecting the abdominal organs has its gas- 
tric or intestinal symptomatology. As an example of this one 
has only to mention any one of the chronic catarrhal condi- 
tions affecting stomach or intestine to bring to mind certain 
so-called symptoms of indigestion and to this must be added 
various abnormal states of pancreas, Hver, kidneys, etc., with 
gastro-intestinal symptoms in order to realize what a loose 
generalization the term "indigestion" denotes. 

Given however, a normal gastro-intestinal canal and acces- 
sory glands there are certain conditions and substances which 
can produce symptoms which pass under this general name; 
various individuals differing in their reaction to different 



298 DIET IN DISEASES OF THE STOMACH 

forms of irritation which may be mechanical, chemical or ther- 
mal in origin. What suits one individual's digestive apparatus 
may have an entirely different effect on another's and one 
has only to mention such substances as lobster, deviled crabs, 
hot breads, certain heavy sweets or fats with a high melting- 
point in order to realize that some people cannot take these 
articles of food without a digestive upset, whether from ana- 
phylactic action or a difference in digestive juices or motor 
function, while still others can take them with impunity. 
Foods, such as those undergoing putrefaction or fermentation, 
almost universally cause a more or less serious disturbance 
because very few possess the abihty to detoxify these materials. 
Then, too, faulty mastication either from bad teeth, or lack 
of more or less of them, is very apt to result in disturbances 
which may be only functional, but are usually in the long- 
standing or chronic cases due to actual pathological lesions of 
the gastro-intestinal tract. Rapid eating acts in the same way, 
also improperly prepared food, to say nothing of vegetable 
substances which are unripe. Experience has shown that 
certain foods are always better borne when cooked than if 
eaten raw, and there is no doubt but that individual racial 
differences and habits cause the digestive apparatus to adjust 
itself to conditions which would spell **ruin" for people not 
accustomed to such a dietary. Could we eat the food of our 
ancestors of the stone age without disaster to our digestions.? 
and the diet of our Eskimo brothers would, if eaten by us, 
cause many a troubled dream. Hence we see that the variety 
of differences in different peoples and different individuals of 
the same people is infinite, not only in face and form, but in 
their reaction to different foods, and it is a wise man who early 
learns his own dietary impossibilities and has the strength of 
mind to avoid them. Still another factor enters into the ques- 
tion of the digestibility of foods, such as for example, the 
psychic effect of anger, fear, etc., which inhibits the action 
of the secretory glands or causes motor irregularities of the 
stomach and intestine. Again the effect of overwork, muscular 
or mental, is often to inhibit the digestive processes with the 
well-known sequelae of digestive disturbance; and everyone 
knows that some foods which may be eaten at one time with- 
out difficulty prove a veritable source of sorrow when taken 
under other circumstances. One might go on almost indefi- 
nitely multiplying the factors which modify the digestibility 
of food-stuffs, but enough has been said to make the fact 
evident that there are individual differences in people, in 
food, and in the circumstances under which the}^ are eaten, 
that play an enormous role in the production of digestive 



GASTRIC HYPERACIDITY, HYPERCHLORHYDRIA 299 

unrest and result in what is generally spoken of as "indigestion" 
in some one of its forms. One must, on the other hand, always 
seek for the underlying cause whether it be a condition of true 
pathology, functional derangement or individual idiosyn- 
crasy, else one easily falls into the habit of thinking of "indi- 
gestion'' as an indefinite, but comfortably large scrap-basket 
into which may be tossed a digestive symptom-complex, with- 
out taking the trouble to really get at its true significance. 



GASTRIC HYPERACIDITY, HYPERCHLORHYDRIA. 

Acid dyspepsia is a very common diagnosis and it is prob- 
ably true that more than half of the patients who consult a 
physician for gastric troubles are found on examination to 
have a hyperacidity due to an excess of free HCl. The time 
has gone by, however, when one can rest content with such a 
diagnosis, for hyperchlorhydria is in almost every, if not in 
every, instance merely a symptom and not a disease entity. 
One must therefore seek for the underlying cause which with 
care can almost always be successfully done. Kaufman s'^ 
classification covers the etiology satisfactorily and divides the 
cases into: 

1. Those with an inborn disposition toward acidity. 

2. Due to faulty habits. 

3. Chronic intoxications. 

4. Reflex from disturbances in other organs (or in the 
stomach itself). 

1. Little is known about the first class except that one occa- 
sionally does find people who have always had a hyperacid 
stomach extending from childhood, without evidence of a 
pathological basis. In these cases, at the same time, must 
be borne in mind possible, but hidden, reflex causes, such as 
chronic appendicitis. 

2. Faulty habits account for a certain number of cases, of 
which may be mentioned, rapid eating, highly spiced foods, a 
great amount of acid food, or very sweet food and mental over- 
work. Students are very prone to have an exacerbation of 
hyperacidity during examination times, whether they have a 
real pathological lesion or not. 

3. Too free use of tobacco in any form accounts for certain 
cases, and for some this means any use whatever of the weed. 
Some patients can smoke cigarettes or cigars in moderation 
without symptoms, while others have been known to precipi- 

^ Kauffman, in Forchheimer, vol. iii, 75. 



300 DIET IN DISEASES OF THE STOMACH 

tate an attack of hyperacidity by a few days of pipe smoking 
so regularly that the pipe has been given up. 

Alcohol, particularly when taken strong on an empty stom- 
ach, in the form of cocktails or neat spirits frequently leads to 
a hyperacidity, and of course an actual catarrh later on if 
persisted in. Some patients cannot take coffee without increas- 
ing considerably the hyperacidity. 

4. The reflex conditions which may produce a hyperacidity 
are legion and one has but to mention chronic appendicitis, 
cholelithiasis, nephroUthiasis and peptic ulcer, to bring to 
mind numberless cases falling into this class. 

Given a case of hyperchlorhydria, if the cause can be found, 
of course treatment and diet must be directed along lines 
suitable for the particular condition at fault, but nevertheless 
a certain number of cases remain which are evidently hyper- 
acidity with the symptoms of pyrosis, eructations, often very 
acid, and some discomfort or burning in the epigastric region 
at the height of digestion. When there is actual pain, repeated 
daily, usually one to three hours after meals, there is almost 
always an organic lesion at fault, but if this can be reasonably 
ruled out, we must take dietetic measures to reduce the 
hyperacidity to a minimum. A diagnosis of hyperacidity can 
only be made satisfactorily by means of a test meal and, in 
fairness to the patient, this precaution should never be 
omitted. 

The Reduction of Gastric Hyperacidity by Diet. — This is done 
first by the avoidance of certain foods which are sure to induce 
a certain amount of physiological increase in acidity, and 
secondarily to give such foods as will render the excess of acid 
as innocuous as possible. To these ends one must avoid tak- 
ing all acids, spices, condiments, salt meat or salt fish, and the 
use of salt on the food should be reduced to the minimum. 
It has been shown possible, in dogs, to feed meat boiled in dis- 
tilled wa:ter until the salt intake is reduced almost to zero, 
when this is done the free hydrochloric acid production is 
actually controlled. This cannot be continued indefinitely in 
human beings, as sodium chloride in a certian minimal amount 
(i or 2 gm. per day) is necessary to health, but all excess can 
be obviated with resulting diminution in acid values in the 
gastric secretion. All foods must be avoided, which b}^ their 
tough consistency would remain in the stomach a long time, 
such as very coarse vegetables, seeds, fruit skins or fats with 
a high melting-point, as mutton fat. Very hot or cold drinks 
or foods act in much the same way and must be left alone. 
Alcohol is especially bad in all forms. Meat soups are stimu- 
lating and are best omitted from the diet as are all hors 



GASTRIC HYPERACIDITY, HYPERCHLORHYDRIA 301 

d'oeuvre, such as caviare, olives and pickles, etc. Very sweet 
food has much the same effect, so all candy, rich cake, heavy 
preserves, sweet jellies must be left out of the diet. 

When one comes to construct a diet suitable for these cases 
one meets at once theoretical objections- to many forms of 
food, and authority can be found for barring carbohydrate or 
protein food, especially meats in all forms, for although they 
have a high combining power for the free HCl, they in turn 
are gastric excitants and would thereby defeat their own 
object. Dietetics based on this view are constructed largely 
of carbohydrates and theoretically these should be well toler- 
ated, but as a matter of fact for one reason or another they 
do not seem to act practically as we should expect, probably 
because although they call out ,a smaller acid secretion, they 
have little to offer to combine with the free HCl, which, once 
it accumulates in any quantity, causes the symptoms for which 
we are attempting to find the ideal diet. Fats do actually 
depress the acid secretions and when of a low melting-point, 
such as sweet butter, or when bland and liquid, as olive, 
peanut or cotton-seed oil, they are very valuable foods in 
hyperacid conditions for this quahty, as well as for their high 
nutritive and caloric value. 

But one cannot live on fats, so that to a certain extent a 
mixed diet must be used. Experience has shown that although 
milk is more or less a gastric stimulant, it offers such a high 
percentage of protein for binding the free HCl, that it is of 
great value, and a few days of a milk or milk-and-cream diet 
is often most useful in quieting an overproductive gastric 
secretion. Eggs are good for the same reason although some 
authorities think that as the fat is in emulsion it is more 
stimulating than should be used, this is not, in the view of 
most cHnicians, of sufficient weight to prevent their free use 
to advantage. The fine cereal preparations, such as farina, 
cream of wheat, malted breakfast food, wheatena, are all 
usable and are better than oatmeal. Bread is at times a 
marked gastric stimulant and Kauffman refers to hyper- 
chlorhydria in vegetarians for which he largely blames the 
excessive use of bread. Stale bread, toast, zweiback or crust 
of roll may be taken by these cases in moderation. 

Diet in Hyperacidity. — ^The diet in hyperacidity may be 
advantageously made up of the following articles, using con- 
siderable quantities of the less stimulating proteins: 

Raw oysters with a very little salt or a few drops of lemon 
juice. 

Soups: Cream or puree (except tomato) and made without 
meat stock. 



302 DIET IN DISEASES OF THE STOMACH 

Fish: All white-meated, non-fatty fish, such as fresh cod, 
halibut, bass, white fish, boiled and served with egg sauce, or 
broiled (never fried). 

Meat: In marked hyperacidity meat is best let alone, except 
occasionally boiled or roasted and chicken or turkey. In less 
severe cases, minced lamb, without fat, guinea hen, well-done 
beef w^ithout gristle, fat or grav}^, in small amounts and never 
more than once a day, may be allowed. 

Vegetables: The soft green vegetables, such as young peas, 
string beans, spinach with egg, beet tops, celery, squash, vege- 
table marrow, rice, all boiled. Baked Hubbard squash, baked 
white potato, spaghetti. (No cabbage, Brussels sprouts, cauli- 
flower or onions to be used on account of their tendency to 
ferment and cause flatulence.) 

Cheese: Cream, Neufchatel, Swiss. 

Desserts: All cream desserts, those made of egg and milk, 
such as custards, blanc mange, floating island, junket, soft 
rice, farina or bread puddings without rich sauces and best 
eaten with cream. Gelatin desserts if not highly flavored, all 
made with the minimum amount of sugar. 

Fruit: None at all in severe cases. In milder cases when 
constipation is marked, soft, subacid, stewed fruits may be 
taken in fair amount, but no fruits with seeds or those with 
tough skins should be used, such as figs, raspberries, black- 
berries, gooseberries and prunes. Fruit should be stewed or 
baked with very little sugar. 

Bread: Toast, dry roll, zweiback, toasted crackers. 

Butter: Either fresh butter, or salted butter, if used, should 
be worked over in fresh water to take out as much of the salt 
as possible. 

Drinks: Weak tea, cocoa made with milk, cream, water, 
Vichy not too cold and never sparkHng. 

Cereals: All fine well-boiled cereals. 

Eggs: In any form but fried or hard-boiled and not made into 
fancy entrees. 

Cake: A little cup cake, angel cake and sponge cake. 

Foods to Avoid: All highly spiced, sour, salty foods, condi- 
ments, pickles, jellies, salted nuts, olives, raw vegetables as 
celery, salads, radishes, etc. Very cold or hot foods or drinks, 
or if taken in small amount they should be kept in the mouth 
long enough to bring their temperature to about body heat. 
Uncooked vegetables of all sorts and hard substances as corn. 
Coff'ee, wines, beer, liquors, cordials, ale, ginger ale and cold 
soft drinks. Pies, syrups, pancakes, hot biscuits, cake other 
than those already mentioned. 



GASTRIC HYPERSECRETION 303 

GASTRIC HYPERSECRETION. 

Since hypersecretion whether intermittent or continuous is 
a symptom of disease and not a disease itself, it is necessary, 
in order to prescribe a rational diet, to know if possible what 
the underlying cause may be. In the intermittent variety we 
may be dealing with merely a part of a general neurosis or it 
may be a gastric manifestation of a lesion of the central ner- 
vous system, such as tabes or lateral sclerosis, where it is 
regularly an accompanying feature of the gastric crisis. It 
may also follow the excessive ingestion of alcohol or gastric 
irritants or accompany acute gastric dilatation (q. v.). 

In the intermittent variety the diet should be arranged so 
far as possible in accord with the etiological factor. Since 
hypersecretion is practically always accompanied by a defi- 
nite hyperchlorhydria the diet should be chosen on the basis 
of the foods recommended for this condition. A few days or 
a week or more of a milk diet with or without the addition of 
very soft-boiled eggs, gives relief to most of the cases, regard- 
less of the etiology, excepting only those cases due to a lesion 
of the central nervous system,, as tabes. The reHef is, how- 
ever, often only symptomatic and a test meal will still show 
hypersecretion and hyperacidity unless in case of ulcer there 
had been actual healing. 

Continuous Hypersecretion is for the most part a symptom 
of gastric or duodenal ulcer and unless this can in some way 
be excluded, as by A;-ray examination, it is fair to assume such 
a relationship, particularly in the presence of ulcer symptoms, 
and institute an ulcer cure. 

The pain which so often accompanies hypersecretion may be 
ascribed probably to pylorospasm or possibly to an irritated 
ulcer and, while a milk diet will also bring relief to this 
symptom it will do so permanently only so far as the diet 
is successful in curing the underlying ulcer. 

While usually a high protein diet is advocated for hyper- 
secretion, it will be seen from what has been said that this is 
rather a shot in the dark and that if one wishes to use foods 
intelHgently it is absolutely necessary to first make an etio- 
logical diagnosis. 

In general it may be said that the protein of milk and egg 
is the best for all cases of hypersecretion, whereas, meat or 
meat products are distinctly stimulating to gastric secretion 
and should be omitted from the diet at first, and later allowed 
only in small amount and in the more easily digested forms, 
e. g., chicken, mutton and sweetbreads. Soft farinaceous pud- 
dings and cereals are allowed in moderation and puree of 



304 DIET IN DISEASES OF THE STOMACH 

vegetables, as in hyperchlorhydria {q. v.). Especial impor- 
tance is attached to the avoidance of condiments, acid food 
and drink, rough foods, skins, seeds, corn, etc., all of which 
remain a long time in the stomach and produce thereby 
irritation, and in addition the thermal irritants, such as very 
hot or very cold foods, are to be avoided. 

GASTRIC HYPOACIDITY AND ACHYLIA GASTRICA. 

Diminution or absence of gastric acid and ferments, as its 
name implies is the direct opposite of hyperchlorhydria and 
may be due to a variety of causes, either organic or functional. 
Of the organic causes any long-standing catarrh of the stomach 
will lead to it and it is found as a frequent compHcation of 
catarrhal gastritis and gastric carcinoma, pernicious anemia, 
severe infectious diseases at times and in many elderly people. 
In any event permanent achylia is accompanied by atrophy of 
the mucous membrane of the stomach and its secreting glands. 

Of the functional causes, many cases are due to profound 
neurasthenic conditions and as a reflex from organic disease 
in some of the other abdominal organs, e. g., chronic appen- 
dicitis or choleHthiasis. There is still another class of case 
in whom the achylia gives rise to no symptoms and is only 
found by accident in the course of a routine examination. 
The cause of this variety is far from clear. 

The degree of the hypoacidity varies within wide limits and 
runs from a slight reduction in the free HCl and total acid 
values and without change in the pepsin-rennin secretion, all 
the way to complete achyha with total absence of acids and 
ferments. In passing, it might be remarked that the acids are 
diminished more frequently and in greater proportion than 
the ferments. In the cases in which the hypoacidity is depend- 
ent on a definite lesion, as for example gastritis, the return of 
the acid is greatly dependent on the outcome of the under- 
lying cause, which if cleared up may result in a return of the 
secretions. Other cases are found without definite cause as 
already stated and remain achylia to the end of the chapter, 
apparently with little eflPect on the general health. 

The diet problem in hypoacidity is in man}^ respects a 
much more simple matter than in most cases of marked 
hyperacidity and within certain limits the foods which are 
inadvisable in hyperchlorhydria on account of their tending 
to excite gastric secretion, are the ones which we may often 
freely use in this opposite condition. 

Mention has already been made of the diet best for these 
cases in connection with chronic gastritis with hypoacidity 



GASTRIC HYPOACIDITY AND ACHYLIA GASTRICA 305 

(p. 309), but it is necessary to go more into detail. Where 
there is a definite organic cause or accompanying condition 
to the hypoacidity or achyHa the diet must be in accordance 
with this compHcating feature and all foods which are in any 
way irritating must be avoided, such as condiments, strong 
acids, very rough or hard foods, skins, seeds, etc., as the 
mucous membrane in many of these cases is exceedingly vul- 
nerable and bleeds easily, even on the introduction of the 
stomach-tube. Very hot foods or large quantities of acid 
food or drinks must be avoided. 

Theoretically very limited protein should be given, as in the 
absence of the normal HCl and pepsin, gastric digestion is at 
a minimum or entirely absent. Within certain Hmits this 
objection holds good, namely for all protein foods difficult of 
digestion, e. g. veal, tough meats of all sorts, connective 
tissue (which latter is only digested in the presence of free 
HCl and pepsin) and tough clams, lobster, etc. On the other 
hand, the patients must receive their full daily allowance of 
protein and will be able to digest the proper kinds in the course 
of pancreatic and intestinal digestion. Of these, milk, eggs, 
tender meats and fowl cut very fine without gristle or con- 
nective tissue, mild cheeses, tender white-meated fish and vege- 
table protein of all sorts must form the bulk of the protein 
ration, but given preferably in only moderate amount say 
from 70 to 90 grams per diem, and not to the high limit allow- 
able in a normal person. While a moderate amount of these 
protein foods can be entirely digested in the intestines, any 
excess will throw too much work on these accessory digestive 
processes which may easily go out of commission on this 
account, with the result that the proteins in excess undergo 
putrefaction in the intestine giving rise to many uncomfort- 
able symptoms of toxemia. This is the more prone to hap- 
pen as the normal gastric juice is a strong antiseptic for all 
foods brought to the stomach and it is a hardy germ that 
can live through the acid immersion it receives there. On this 
account the normal chyme is comparatively free from bac- 
teria; a fortunate provision of nature when one considers the 
quantity of poor gastric surgery that is done, much of which 
would be followed by greater disaster w^ere it not for this fact. 

Since the natural barrier to the entrance of pathological 
bacteria is largely or entirely missing in these cases of hypo- 
acidity, it is of the greatest importance that the food taken he 
all thoroughly cooked to render it sterile. Fruit with skins may 
be an exception to this rule, as they are really practically 
sterile within their skins. For the same reason great care 
should be taken of the mouth and its toilet made before and 
20 



306 DIET IN DISEASES OF THE STOMACH 

after meals, using toothpick, dental floss, tooth brush and a 
good mouth wash. This seems excessive care, but many 
cases of diarrhea and chronic intestinal infection are started 
by reason of carelessness in these respects. 

Clear soups are good for their appetizing and stimulating 
effects on the gastric glands that are still capable of stimu- 
lation and other protein foods as already indicated, may be 
eaten. All vegetables that are soft and non-irritating, fats, 
particularly butter and oils and cream. AH carbohydrate 
foods are easily digested as the gastric ptyahn digestion pro- 
ceeds uninterruptedly in the absence of gastric acidity. At 
the same time excessive use of sweets should be avoided as 
likely to disturb digestion. All simple desserts may be used to 
advantage. 

There is still another condition which must be reckoned 
with in these patients, namely, that while the gastric motility 
is usually well preserved in all but cancer cases, there may be 
the opposite condition of gastric atony. In this latter com- 
plication one may use the same class of foods as recommended 
for the cases with good motility, but they should be given in 
smaller amounts and at more frequent intervals, following 
generally the dietetic rules laid down for atony, particularly 
with reference to restricted fluids at meals. 

Many of these cases of achylia are complicated by diarrhea 
probably of pancreatic origin, at all events there are few more 
brilliant results in medicine than those obtained in most of 
these cases of achylia diarrhea by the giving of dilute HCl, 
either alone or with pepsin; and all cases of unexplained and 
long-standing diarrhea should have determined, by a gastric test 
meal, the presence or absence of HCl. 

The addition of this dilute acid to the dietary in all cases 
of achylia is of distinct advantage, although it must not be 
given in too large doses and later when digestion is regulated 
it may be possible to omit the acid altogether. 

GASTRITIS. 

Acute Gastritis. — Acute gastritis, except that caused b}^ a 
toxicosis, must be considered a rare disease, in spite of the 
frequency of the diagnosis. When the toxicosis is constitu- 
tional of course the dietary treatment is along lines laid down 
for the particular disease at fault, e. g., renal insufficiency, etc. 
There are however, a fair number of cases caused by the 
direct effect of irritating substances such as strong acids, 
alkalis and abuse of condiments, but most frequent of all, 
the excessive use of alcohol; and it is after a drinking bout 



GASTRITIS 307 

that this is most frequently met with. In any case, the cause 
being what it may, the dietary treatment is practically the 
same. 

The first step is starvation, nothing whatever should be 
given by mouth and the fluids which the system craves in 
severe cases accompanied by much nausea and vomiting, may 
be supplied by the rectum, either in the form of a Murphy 
drip or by giving from six to eight ounces of warm saline by 
rectum, every two, three or four hours. After twelve to 
twenty-four hours, or when the vomiting has ceased, one may 
begin to feed small amounts of cold peptonized milk, or kou- 
myss, buttermilk, white of egg in dilute orange juice beaten 
up and strained; milk; Vichy or Delafield's mixture:^ begin- 
ning all in very small amounts (a teaspoonful every twenty to 
thirty minutes) and increasing the amount and lengthening the 
interval. In certain cases, small amounts of iced champagne 
or ice-cold ginger ale are well borne and may even be of 
assistance in controlling the vomiting. 

In acute gastritis or esophagitis, due to taking a corrosive 
poison, demulcent drinks are of especial value in not only 
supplying some nourishment, but in quieting an inflamed 
mucous membrane. Of these drinks a thin solution of gum 
arabic (2 to 5 per cent.) flavored with a little orange juice is 
acceptable. Also a solution of Iceland moss made in the 
same way. After the acute stage is past one begins with 
gruels, fine cereals, milk, plain or diluted; then soft sohds and 
on up the scale until the full diet is reached. All rough, 
highly spiced and peppery, very hot or very cold foods and 
drinks should be avoided for some time. 

Chronic Gastritis. — In contradistinction to the acute vari- 
ety, chronic gastritis is fairly frequently seen and is practi- 
cally always secondary to a chronic disease with poor ehmi- 
nation, to chronic congestion, as in hepatic cirrhosis or car- 
diac decompensation or a chronic form of irritation of which 
latter of course, alcohol is the chief e^tample. During an 
acute exacerbation the diet should be the same as that detailed 
for acute gastritis. When the disease is found in its later 
stages many digestive symptoms are traceable to its presence. 
In arranging the diet for such cases it is almost absolutely 
essential to have an analysis of a gastric test meal for diag- 
nosis, as many digestive symptoms referred to the stomach 
and lumped as chronic gastritis are nothing of the sort. They 
are quite as likely due to secretory or motor disturbances, 

' Delafield's mixture: Cream, oz. 4; milk, oz. 4; Vichy, oz. 4; soda bicarbonate, 
gr. 20; cerium oxalate, gr. 10. 



308 DIET IN DISEASES OF THE STOMACH 

often secondary to other conditions such as peptic ulcer, 
chronic appendicitis or gall-bladder disease, and have nothing 
to do with an increased production of mucus, which is a 
sine qui non of true gastritis. 

Then too, some cases of chronic gastritis are accompanied by 
hyperacidity, others by normal or hypoacidity running even 
into an achyHa gastrica, the certain knowledge of which will 
be of great assistance in selecting a proper dietary. 

In ger ral it may be said that after removal of the cause, 

whenever that is possible, a certain amount of rest and the 

entire ab'"sence of all irritating food should be insisted upon. 

Diet. — When the gastritis is accompanied by hyperacidity, 

the following articles of food should be forbidden : 

Salt foods, spiced-'. foods, acid foods, rough or mechanically 
irritating foods, fermented foods, e. g., wines, beers and ales. 
Of course, no case of gastritis should take alcohol in any form 
except possibly when the patient has been long accustomed 
to its use, a little whisky or red wine, both diluted with Vichy, 
may be allowed for a short time. Nothing very hot or very 
cold is allowed. On the other hand, as there is usually good 
digestive power to the secretions, a fairly high protein allow- 
ance of a non-stimulating sort may be allowed. In a general 
way the diet may be advised as follows : 

Early morning on awakening a half-glass of warm Hopital 
or Celestin Vichy, or water with half a teaspoonful of arti- 
ficial Vichy salts. This taken at least one-half hour before 
breakfast, acts as a gastric lavage. If the bowels are consti- 
pated an occasional small dose of some of the laxative soda 
salts may be given, phosphate or sulphate of soda. 

Breakfast: Cocoa, made with milk, or weak tea; fine 
cereal — farina, cream of wheat, wheatena with cream, 
and very little sugar; soft toast or soft part of stale 
bread, well chewed; eggs in any simple form. Later, 
apple sauce or baked sweet apple. 
Luncheon, Dinner or Supper: Cream or puree soup (no 
meat stock). Simple egg entree. A little boiled 
chicken or young lamb, scraped or finely cut beef, all 
without rich gravies or sauces; puree of soft, green 
vegetables, put through a colander, without seeds or 
rough cellulose or skins; cauliflower, cabbage or 
tomatoes are not allowed, desserts, soft custards, pud- 
dings, gelatin desserts with cream, cream desserts; 
ice-cream occasionally. Later, soft stewed fruits, not 
acid, and cooked with little sugar; junket. 
Beverages: Alkaline waters, Vichy, High Rock, plain water; 
cocoa or weak tea; milk. 



PEPTIC ULCER {GASTRIC AND DUODENAL) 309 

Milk food should be reduced to a minimum in the presence of 
gastric atony. The quantity of food given at each feeding and 
the length of the feeding intervals will depend on the condition 
of gastric motility. When this is good, three normal-sized meals 
may be given, when impaired, frequent, small, dry feedings 
are better. This is of course, true of gastritis by whatever 
degree of acidity it is accompanied. (See Diet in Gastric 
Atony.) It is advisable to eat a meal which is easily digested 
and passed into the intestine as rapidly as possible ^o giving 
the maximum degree of rest to the stomach. 

Diet when Gastritis is Accompanied by Hypoacidity or 
Achylia. — Early morning alkaline waiters as for hyperacid 
cases, except that to them, may be added a little sodium 
chloride; or Carlsbad water or sodium s::.'ts may be allowed 
when constipation is present, or plain water, six ounces (i8o c.c.) 
with salt gr. v (§ gm.), soda bicarbonate gr. xv (i gm.). The chief 
difference in the diet from that given for hyperacid cases is 
that less meat protein is allowed. Stewed fruits may be used 
earlier than in hyperacid cases and stock soups are permitted 
largely for their appetizing quaUties. With impaired motil- 
ity, however, soup of all kinds is best omitted, as fluids then 
leave the stomach slowly. Water should be taken in only 
small amounts with meals and it is well to order patients 
to drink water about an hour before meals, between meals 
and at bedtime. 



PEPTIC ULCER (GASTRIC AND DUODENAL). 

In the acute and so-called medical ulcer of the stomach or 
duodenum or in the acute exacerbation of a chronic ulcer, the 
management and dietary are the chief essentials, excepting, of 
course, those cases which on account of some compHcation 
demand surgical intervention. In response to this need, there 
have sprung up a number of different forms of treatment, 
some advocates of all of them being found in each community. 
The fact that the acute medical ulcer has a tendency to heal 
spontaneously, if given a fair chance, probably accounts for 
the claims of one or another of the different methods in vogue. 
With the acute exacerbation of a chronic ulcer it is somewhat 
different and although the acute symptoms may promptly 
subside when treated as an acute simple ulcer, the ultimate 
end sought, namely cicatrization of the old ulcer is a most 
uncertain chance, although it does take place in perhaps a 
larger proportion of cases than the surgeons would have us 
believe, as proved' by autopsy findings. The gastric and duo- 
denal ulcers are dealt with together, as their dietary treatment 
is identical. 



310 DIRT IN DISEASES OF THE STOMACH 

The Chief Methods of Dietary Treatment for ulcer may be 
classed as: 

1. Absolute physiological rest to the upper digestive tract, 
with later mouth feedings either with or without rectal 
alimentation in addition. 

2. Almost continuous, but reduced, physiological activity 
of the same region but with food that is in small amounts, 
principally protein and which has the quahty of quickly bind- 
ing the free hydrochloric acid, turning the albumin into the 
comparatively unirritating syntonin, and of leaving the 
stomach quite promptly. 

3. Transgastric or duodenal feedings. 

4. An essential feature of still another form of treatment 
is the use of alkalies to reduce the exaggerated acidity, usually 
present in these cases, together with the feeding of small quan- 
tities at frequent intervals of highly albuminous foods. The 
use of alkalies may, of course, be combined with any one of 
the forms of treatment and has many advocates. 

The first plan has the disadvantage, if carried out to the 
letter, of almost complete starvation during the time of diges- 
tive rest. Where this has been modified by attempts at rectal 
feeding or water is introduced by rectum, physiology has shown 
that at once peristaltic unrest is set up throughout the entire 
gastro-intestinal tract and it also gives rise to gastric secretion. 

Von Leube Diet in Ulcer. — In the first type of diet as exempli- 
fied by the von Leube cure and modified most satisfactorily 
by G. R. Lockwood, absolute rest is given for three days and 
not even water is allowed, but the mouth is kept moist by 
mouth washes. If after twenty-four to forty-eight hours the 
thirst becomes too excessive, the Murphy drip is instituted 
whereby from twenty to fifty drops of normal saline solution 
are allowed to flow into the rectum each minute, depending 
on the patient's rectal tolerance. In patients who are old, 
feeble or desiccated by vomiting and insufl&cient food before 
hand, the first period of starvation is limited to twenty-four 
hours. 

On the second day in these cases, and the third day in 
sthenic cases, 2 ounces of Celestin or Hopital Vichy is 
given every two hours and the following day this is alternated 
with 2 ounces of albumin water, so that liquids are there- 
fore given every hour. Von Leube also recommends very 
strongly the continuous use of local heat over the upper abdo- 
men, either as hot compresses or the use of the electric pad 
over a moist compress, except in cases of recent hemorrhage. 
On the next day fully peptonized milk, 2 ounces at each 
feeding, every two hours is alternated with the Vichy, so that 



PEPTIC ULCER (GASTRIC AND DUODENAL) 811 

the patient gets one or the other every hour. During the 
first few days of this diet, if the thirst is troublesome, either 
the Murphy drip can be given or from 4 to 6 ounces of 
warm saHne may be given by rectum every three or four 
hours. Each day the peptonized milk is increased i ounce, 
until 8 ounces are being taken. The Vichy is increased 
I ounce daily until 4 ounces are given at a time. Both 
Vichy and fully peptonized milk^ have been shown by Cannon 
to leave the stomach very rapidly. The bowels are kept regu- 
lar by enemeta and if there is troublesome gastric acidity, 
alkaHne powders are given. About the tenth day soft milk 
toast, junket or fine cereal may be added. It is well to add 
these to one of the peptonized milk feedings, then to two, three 
or until with every other milk feeding the patient gets a soft 
solid. In the third week, the quantities may be increased and 
creamed mashed potato, fresh creamed halibut or cod fish, 
macaroni, puree soups made without meat stock are added, 
also puree of vegetables, such as puree of peas. Farinaceous 
desserts can then be added, such as cornstarch, farina, blanc 
mange and custard. All these three weeks the patient remains 
in bed, still continuing the hot applications. During the 
fourth week they may be allowed up in a chair and put gradu- 
ally on any soft food, leaving out fruit, coffee, acids, irritants 
of all kinds, whether mechanical, thermal or chemical. 

This dietary cure takes time and cannot be hurried if one 
wishes to give the patient the best chance of recovery. When 
the mouth feedings have begun some clinicians prefer to use 
nutrient enemata as an additional supply of fluid and some 
nourishment. The best food for this purpose is undoubtedly 
fully peptonized milk, the same as that given by mouth with 
or without the addition of glucose sufficient to make a 2 to 
4 per cent, solution. Often the milk alone is better borne 
in varying quantities, some patients taking as much as i 
pint every six hours, others a less amount at more frequent 
intervals, all of which must be determined for each case 
individually. (For details see Rectal Feeding.) 

Those who prefer to use the von Leube diet as originally 
outlined by him, will find the following plan useful. 

Von Leube 's Diet^ (Original) : 

^ For complete peptonization .of milk. Lockwood's directions for full pepton- 
ization are most satisfactory. Divide a quart of milk in half, bring one- 
half (i pt.) to boiling and add the other cold pint. This produces the correct 
temperature. To this add two tubes of Fairchild's peptonizing powder rubbed up 
in 4 ounces of water. Put the milk in scalded bottles and stand in a pail of 
water at 105° F. and keep there with occasional shaking for two hours. Then 
scald and put on ice. 

2 Smith: What to Eat and Why, p. 193. 



312 DIET IN DISEASES OF THE STOMACH 

First Three Days: 

7 A.M. 150 c.c. of milk (5 oz.). 

8 a.m. 150 c.c. of milk (5 oz.). 

10 A.M. 150 c.c. of milk (5 oz.) with strained barley 

water. 

11 A.M. 150 c.c. of milk (5 oz.). 

I P.M. 150 c.c. bouillon with peptone preparation. 
Fourth to Eleventh Day: 
7 to 9 A.M. 300 C.C. of milk (10 oz.). 

II A.M. 300 c.c. of milk with barley, rice or oatmeal 
water. 
I P.M. One cup of bouillon (200 c.c.) with a beaten egg. 
3 to 5 P.M. 300 c.c. of milk (10 oz.). 
7 P.M. Milk with barley water. 

9 P.M. 300 c.c. of milk (10 oz.). 
Eleventh to Fourteenth Day: 

7 to 9 A.M. 300 C.C. of milk (10 oz.), and two crackers, soft- 
ened with barley water. 
II A.M. 300 c.c. of milk (10 oz.). 
I P.M. 200 c.c. bouillon (6J oz.), one egg, two crackers. 
3 P.M. 300 c.c. of milk (10 oz.), one egg. 
5 P.M. 300 c.c. of milk (10 oz.), two crackers. 
7 P.M. Milk with barley water. 
9 P.M. 300 c.c. of milk (10 oz.). 
Fourteenth to Seventeenth Day: 
7 to 9 to II A.M. As above. 

I P.M. Scraped meat 50 gm. (if oz.), two crackers, one 
cup of bouillon, 200 c.c. (6J oz.). 

3 P.M. 300 c.c. of milk (10 oz.). 

5 P.M. 300 c.c. of milk (10 oz.), one soft-boiled egg, two 

crackers. 
7 P.M. 300 c.c. of milk (10 oz.) with farina. 
9 P.M. 300 c.c. of milk (10 oz.). 
Seventeenth to Twenty-fourth Day: 

7 A.M. Two soft-boiled eggs, butter (i gm.), toasted 

bread 50 gm. (if oz.), 300 c.c. of milk (10 oz.). 
10 A.M. 300 c.c. of milk (10 oz.), crackers 50 gm. 

(if oz.). 
I P.M. Broiled lamb chop 50 gm. (if oz.), mashed 

potato 50 gm. (if oz.), butter 10 gm. (f oz.), 

cup of bouillon 200 c.c. (6J oz.). 

4 P.M. Same as 10 a.m. 

6.30 P.M. 300 c.c. (10 oz.) of milk with farina, crackers 
50 gm. (if oz.), butter 20 gm. (f oz.). 
9 P.M. 300 c.c. milk (10 oz.). 



PEPTIC ULCER {GASTRIC AND DUODENAL) 313 

Of the second method of feeding these cases, viz., that of 
continued physiological activity with small amounts of bland 
and highly albuminous food, the Lenhartz diet is the best 
known and most generally used. One great object of this diet 
is to do away with any period of actual starvation, on the 
principle that the better nourished a patient can be kept the 
greater chance for healing. In addition, what has already 
been said, in regard to the favorable influence of the rapid 
combining of the free hydrochloric acid with the albumin in 
the diet, of which there is a great abundance, holds true. 

General Directions for Lenhartz's Diet. — Patients must be in 
bed and kept there the entire time, not even allowed up for 
use of the commode; naturally the best and sunniest room 
available should be chosen for ail of these cases, regardless of 
the form of diet. 

The eggs used in each day's feedings should be beaten up 
raw and divided equally into seven feedings, putting the feed- 
ings into seven medicine or small glasses for accuracy and 
keeping them all in the ice-box until used. The milk used 
for the day should be put on ice and the feeding spoon 
kept on ice. All feedings should be very slowly given by 
spoonfuls. A very Httle salt may be allowed on the egg feed- 
ings, otherwise none. As will be seen from the schedule 
of feedings, they are given every hour from 7.00 a.m. to 7.00 
P.M., or 8.00 A.M. to 8.00 P.M. if more convenient, leaving 
a full twelve-hour rest. The following are the details of each 
day's diet: 

First Day. 

7.00 A.M. Egg. 

8.00 A.M. Milk, 20 c.c. (f oz.). 

9.00 A.M. Egg. 

10.00 A.M. Milk, 20 c.c. (f oz.). 

11.00 A.M. Egg. 

12.00 NOON Milk, 15 c.c. (J oz.). 

1. 00 P.M. Egg. 

2.00 P.M. Milk, 15 c.c. (i oz.). 

3.00 P.M. Egg. 

4.00 P.M. Milk, 15 c.c. (i oz.). 

5.00 P.M. Egg. 

6.00 P.M. Milk, 15 c.c. (J oz.). 

7.00 P.M. Egg. 

Total, first day, eggs (raw), 2; milk, 100 c.c. (3§ oz.); 
calories, 280. 



314 DIET IN DISEASES OF THE STOMACH 

Second Day. 

7.00 A.M. Egg. 

8.00 A.M. Milk, 35 c.c. (i oz.). 

9.00 A.M. Egg. 

10.00 A.M. Milk, 35 c.c. (i oz.). 

11.00 A.M. Egg. 

12.00 NOON Milk, 35 c.c. (i oz.). 

1. 00 P.M. Egg. 

2.00 P.M. Milk, 35 c.c. (i oz.). 

3.00 P.M. Egg. 

4.00 P.M. Milk, 35 c.c. (i oz.). 

5.00 P.M. Egg. 

6.00 P.M. Milk, 30 c.c. (i oz.) 

7.00 P.M. Egg. 

Total, second day, eggs (raw), 3; milk, 200 c.c. (6f oz.); 
calories, 470. 

Third Day. 

7.00 A.M. Egg; sugar, 2 gm. (J dr.). 

8.00 A.M. Milk, 50 c.c. (if oz.). 

9.00 A.M. Egg; sugar, 3 gm. (f dr.). 

10.00 A.M. Milk, 50 c.c. (if oz.). 

11.00 A.M. Egg; sugar, 3 gm. (f dr.). 

12.00 NOON Milk, 50 c.c. (if oz.). 

1. 00 P.M. Egg; sugar, 3 gm. (J dr.). 

2.00 P.M. Milk, 50 c.c. (if oz.). 

3.00 P.M. Egg; sugar, 3 gm. (| dr.). 

4.00 P.M. Milk, 50 c.c. (if oz.). 

5.00 P.M. Egg; sugar, 3 gm. (f dr.). 

6.00 P.M. Milk, 50 c.c. (if oz.). 

7.00 P.M. Egg; sugar, 3 gm. (f dr.). 
Total, third day, eggs (raw), 4; milk, 300 c.c. (10 oz.); 

sugar, 20 gm. (5 dr.); calories, 637. 

Fourth Day. 

7.00 A.M. Egg; sugar, 2 gm. (J dr.). 

8.00 A.M. Milk, 70 c.c. (2 J oz.). 

9.00 A.M. Egg; sugar, 3 gm. (f dr.). 

10.00 A.M. Milk, 70 c.c. (2J oz.). 

11.00 A.M. Egg; sugar, 3 gm. (f dr.). 

12.00 NOON Milk, 65 c.c. (2 oz.). 

i.oo P.M. Egg; sugar, 3 gm. (J dr.). 

2.00 P.M. Milk, 65 c.c. (2 oz.). 

3.00 P.M. Egg; sugar, 3 gm. (f dr.). 

4.00 P.M. Milk, 65 c.c. (2 oz.). 



PEPTIC ULCER (GASTRIC AND DUODENAL) 315 

Fourth Day — (Continued). 

5.00 P.M. Egg; sugar, 3 gm. (f dr.). 
6.00 P.M. Milk, 65 c.c. (2 oz.). 
7.00 P.M. Egg; .sugar, 3 gm. (f dr.). 
Total, fourth day, eggs (raw), 5; milk, 400 c.c. (13J0Z.); 
sugar, 20 gm. (5 dr.); calories, yjy. 

Fifth Day. 

7.00 A.M. Egg; sugar, 4 gm. (i dr.). 

8.00 A.M. Milk, 80 c.c. (2I oz.). 

9.00 A.M. Egg, sugar, 4 gm. (i dr.). 

10.00 A.M. Milk, 80 c.c. (2I oz.). 

11.00 A.M. Egg; sugar, 4 gm. (i dr.). 

12.00 NOON Milk, 80 c.c. (2f oz.). 

i.oo P.M. Egg; sugar, 4^ gm. (i dr.). 

2.00 P.M. Milk, 80 c.c. (2I oz.). 

3.00 P.M. Egg; sugar, 4^ gm. (i dr.). 

4.00 P.M. Milk, 80 c.c. (2f oz.). 

5.00 P.M. Egg; sugar, 4^ gm. (i dr.). 

6.00 P.M. Milk, 90 c.c. (3 oz.). 

7.00 P.M. Egg; sugar, 4^ gm. (i dr.). 
Total, fifth day, eggs (raw), 6; milk, 500 c.c. (i6| oz.); sugar, 

30 gm. (i oz.); calories, 966. 

Sixth Day. 

7.00 A.M. Egg; sugar, 4 gm. (i dr.). 

8.00 A.M. Milk, 100 c.c. (3 J oz.). 

9.00 A.M. Egg; sugar, 4^ gm. (i dr.)'; scraped beef, 12 

gm. (3 dr.). 
10.00 A.M. Milk, TOO c.c. (3J oz.). 
11.00 A.M. Egg; sugar, 4^ gm. (i dr.). 
12.00 NOON Milk, 100 c.c. (3^ oz.). 
1.00 P.M. Egg; sugar, 4^ gm. (i dr.); scraped beef, 12 

gm. (3 dr.). 
2.00 P.M. Milk, 100 c.c. (3J oz.). 
3.00 P.M. Egg; sugar, 4^ gm. (i dr.). 
4.00 P.M. Milk, 100 c.c. (3I oz.). 
5.00 P.M. Egg; sugar, 4 gm. (i dr.); scraped beef, 12 

gm. (3 dr.). 
6.00 P.M. Milk, TOO c.c. (3^ oz.). 
7.00 P.M. Egg; sugar, 4! gm. (i dr.). 
Total, sixth day, eggs (raw), 7; milk, 600 c.c. (20 oz.); 
sugar, 30 gm. (i oz.); scraped beef, 36 gm. (9 dr.); calories, 

II35- 



316 DIET IN DISEASES OF THE STOMACH 

Seventh Day. 

7.00 A.M. I soft-boiled egg. 

8.00 A.M. Milk, 100 c.c. (3§ oz.). 

9.00 A.M. Egg; sugar, 13 gm. (3 d^). 
10.00 A.M. Milk, 100 c.c. (3^ oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 33 gm. (i oz.). 
11.00 A.M. I soft-boiled egg. 
12.00 NOON Milk, 125 c.c. (4 oz.). 

1. 00 P.M. Egg; sugar, 13 gm. (3 dr.). 

2.00 P.M. Milk, 125 c.c. (4 oz.); scraped beef, 23 gm. 
(6 dr.); boiled rice, 33 gm. (i oz.). 

3.00 P.M. I soft-boiled egg. 

4.00 P.M. Milk, 125 c.c. (4 oz.). 

5.00 P.M. Egg; sugar, 14 gm. (3^ dr.). 

6.00 P.M. Milk, 125 c.c. (4 oz.); scraped beef, 24 gm. 
(6 dr.); boiled rice, 34 gm. (i oz.). 

7.00 P.M. I soft-boiled egg. 

Total, seventh day, eggs (raw), 4; soft-boiled, 4; milk, 700 
c.c. (23 J oz.); sugar, 40 gm. (i| oz.); scraped beef, 70 gm. 
(2§ oz.); boiled rice, 100 gm. (3I oz.), with beef juice; calories, 
1580. 

Eighth Day. 

The diet changes on the eighth day, requiring only four raw 
eggs, which may be divided into three feedings. The other 
four eggs are to be soft-boiled and given as directed by diet. 

7.00 A.M. I soft-boiled egg. 
8.00 A.M. Milk, 135 c.c. (4J oz.). 
9.00 A.M. Egg; sugar, 13 gm. (3 dr.). 
10.00 A.M. Milk, 133 c.c. (4! oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 33 gm. (i oz.). 
11.00 A.M. I soft-boiled egg; zweiback, 10 gm. (2 J dr.). 
12.00 NOON Milk, 133 c.c. (4i oz.). 
i.oo P.M. Egg; sugar, 13 gm. (3 dr.). 
2.00 P.M. Milk, 133 c.c. (4J oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 33 gm. (i oz.). 
3.00 P.M. I soft-boiled egg. 
4.00 P.M. Milk, 133 c.c. (4i oz.). 
5.00 P.M. Egg; sugar, 14 gm. (3^ dr.); zwieback, 10 gm. 

(2i dr.). 
6.00 P.M. Milk, 133 c.c. (4J oz.); scraped beef, 24 gm. 

(6 dr.); boiled rice, 34 gm. (i oz.). 
7.00 P.M. I soft-boiled egg. 



PEPTIC ULCER {GASTRIC AND DUODENAL) 317 

Eighth Day — (Continued). 

Total, eighth day, eggs (raw), 4; soft-boiled, 4; milk, 800 
c.c. (26I oz.); scraped beef, 70 gm. (zj oz.); boiled rice, 100 
gm. (3 J oz.); zwieback, 20 gm. (5 dr.); sugar, 40 gm. {i\ oz.); 
calories, 1720. 

Ninth Day. 

7.00 A.M. I soft-boiled egg. 
8.00 A.M. Milk, 150 c.c. (5 oz.). 
9.00 A.M. Egg; sugar, 13 gm. (3 dr.). 
10.00 A.M. Milk, 150 c.c. (5 oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 66 gm. (2 oz.). 
11.00 A.M. I soft-boiled egg; zwieback, 20 gm. (5 dr.). 
12.00 NOON Milk, 150 c.c. (5 oz.). 
1. 00 P.M. Egg; sugar, 13 gm. (3 dr.). 
2.00 P.M. Milk, 150 c.c. (5 oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 6j gm. (2 oz.). 
3.00 P.M. I soft-boiled egg; zwieback, 20 gm. (5 dr.). 
4.00 P.M. Milk, 150 c.c. (5 oz.). 
5.00 P.M. Egg; sugar, 14 gm. (3! dr.). 
6.00 P.M. Milk, 150 c.c. (5 oz.); scraped beef, 24 gm. 

(6 dr.); boiled rice, 6j gm. (2 oz.). 
7.00 P.M. I soft-boiled egg. 
Total, ninth day, eggs (raw), 4; cooked, 4; milk, 900 c.c. 
(30 oz.); sugar, 40 gm. (ij oz.); scraped beef, 70 gm. (2J oz.); 
rice, 200 gm. (6f oz.); zwieback, 40 gm. (i| oz.) or toast, 
20 gm. (dr.); calories, 2138. 

Tenth Day. 

7.00 A.M. I soft-boiled egg. 
8.00 A.M. Milk, 166 c.c. (5J oz.). 
9.00 A.M. Egg; sugar, 13 gm. (3 dr.). 
10.00 A.M. Milk, 168 c.c. (5 J oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 66 gm. (2 oz.). 
11.00 A.M. I soft-boiled egg; zwieback, 20 gm. (5 dr.); 

butter, 4 gm. (i dr.). 
12.00 noon Cooked chopped chicken, 25 gm. (6 dr.); milk, 

166 c.c. (5I oz.). 
i.oo P.M. Egg; sugar, 13 gm. (3 dr.). 
2.00 P.M. Milk, 166 c.c. (5i oz.); scraped beef, 23 gm. 

(6 dr.); boiled rice, 66 gm. (2 oz.); butter, 

4 gm. (i dr.). 
3.00 P.M. I soft-boiled egg; zwieback, 20 gm. (5 dr.); 

butter, 4 gm. (i dr.). 
4.00 P.M. Cooked chopped chicken, 25 gm. (6 dr.). 
5.00 P.M. Egg; sugar, 14 gm. (3^ dr.). 



318 DIET IN DISEASES OF THE STOMACH 

Tenth Day — (Continued). 

6.00 P.M. Milk, i66 c.c. (5 J oz.); scraped beef, 24 gm. 
(6 dr.); boiled rice, 67 gm. (2 oz.); butter, 
4 gm. (i dr.). 
7.00 P.M. I soft-boiled egg. 
Total, tenth day, eggs (raw), 4; cooked, 4; milk, 1000 c.c. 
(33 J oz.); sugar, 40 gm. (ij oz.); scraped beef, 70 gm. (2J oz. ; 
boiled rice, 200 gm. (6| oz.); zwieback, 40 gm. {i\ oz.), or 
toast, 20 gm. (5 dr.); chicken, 50 gm. (if oz.); butter, 20 gm. 
(5 dr.); calories, 2478. 

Eleventh Day. 

7.00 A.M. I soft-boiled egg; milk, 250 c.c. (8J oz.); zwie- 
back, 10 gm. (2I dr.); butter, 4 gm. (i dr.). 

8.00 A.M. Egg; sugar, 13 gm. (3 dr.); scraped beef, 20 
gm. (5 dr.); boiled rice, 75 gm. (2^ oz.); 
zwieback, 10 gm. (2 J dr.); butter, 6 gm. 
(li dr.). 
11.00 A.M. I soft-boiled egg; milk, 250 c.c. (8 J oz.); but- 
ter, 6 gm. (i J dr.); zwieback, 10 gm. (2 J dr.). 

1. 00 P.M. Egg; sugar, 13 gm. (3 dr.); cooked chopped 
chicken, 25 gm. (6 dr.); boiled rice, 75 gm. 

(2i OZ.). 

3.00 P.M. I soft-boiled egg; milk, 250 c.c. (8 J oz.); 
scraped beef, 20 gm. (5 dr.); boiled rice, 75 
gm. (2 J oz.); zwieback, 10 gm. (2 J dr.); 
butter, 6 gm. (ij dr.). 
5.00 P.M. Egg; sugar, 14 gm. (3^ dr.); cooked chopped 
chicken, 25 gm. (6 dr.); boiled rice, 75 gm. 
(2 J oz.); butter, 6 gm. (i§ dr.). 
7.00 P.M. I soft-boiled egg; milk, 250 c.c. (8 J oz.); zwie- 
back, 10 gm. (2 J dr.); butter, 6 gm. (i J dr.); 
scraped beef, 30 gm. (i oz.). 
Total, eleventh day, eggs (raw), 4; cooked, 4; milk, 1000 
c.c. (33^ oz.); butter, 40 gm. (ij oz.); sugar, 40 gm. {i\ oz.); 
scraped beef, 70 gm. (2 J oz.); boiled rice, 300 gm. (10 oz.); 
zwieback, 60 gm. (2 oz.); chicken, 50 gm. (if oz.); calories, 
2941. 

Twelfth Day. 

7.00 A.M. I soft-boiled egg; milk, 250 c.c. (8§ oz.); zwie- 
back, 10 gm. (2^ dr.); butter, 4 gm. (i dr.). 

9.00 A.M. Egg; sugar, 13 gm. (3 dr.); scraped beef, ^^ 
gm. (i oz.); boiled rice, 75 gm. (2 J oz.); 
zwieback, 10 gm. (2-^- dr.); butter, 6 gm. 
(If dr.). 



PEPTIC ULCER (GASTRIC AND DUODENAL) 319 

Twelfth Day — (Continued). 

ii.oo A.M. I soft-boiled egg; milk, 250 c.c. (8 J oz.); zwie- 
back, 20 gm. (5 dr.); butter, 6 gm. (ij dr.). 
1. 00 P.M. Egg; sugar, 13 gm. (3 dr.); cooked chopped 
chicken, 25 gm. (6 dr.); boiled rice, 75 gm. 
(2 J oz.); zwieback, 10 gm. (2^ dr.); butter, 
6 gm. (ij dr.). 
3.00 P.M. I soft-boiled egg; milk, 250 c.c. (8 J oz.); 

scraped beef, 35 gm. (i oz.); boiled rice, 50 
gm. (if oz.); zwieback, 10 gm. (2J dr.); 
butter, 6 gm. (ij dr.). 
5.00 P.M. Egg; sugar, 14 gm. (3 J dr.); cooked chopped 
chicken, 25 gm. (6 dr.); boiled rice, 75 gm. 
(2 J oz.); zwieback, 10 gm. (2^ dr.); butter, 
6gm. (li dr.). 
7.00 P.M. I soft-boiled egg; milk, 250 c.c, (8§ oz.); zwie- 
back, 10 gm. (2^ dr.); butter, 6 gm. (i| dr.). 
Total, twelfth day, eggs (raw), 4; cooked, 4; milk, 1000 c.c. 
(33 J oz.); sugar, 40 gm. (i§ oz.); scraped beef, 70 gm. (2| oz.); 
boiled rice, 300 gm. (10 oz.) ; zwieback, 80 gm. (2| oz.) ; chicken, 
50 gm. (if oz.); butter, 40 gm. (l^ oz.); calories, 2941. 

Thirteenth Day. 

7.00 A.M. I soft-boiled egg; milk, 142 c.c. (4f oz.); zwie- 
back, 10 gm. (2i dr.); butter, 4 gm. (i dr.). 

9.00 A.M. Egg; sugar, 13 gm. (3 dr.); milk, 142 c.c. 
(4f oz.); scraped beef, 20 gm. (5 dr.); boiled 
rice, 75 gm. (2^ oz.); zwieback, 20 gm. 
(5 dr.); butter, 6 gm. (ij dr.). 
11.00 A.M. I soft-boiled egg; milk, 144 c.c. (5 oz.); zwie- 
back, 10 gm. (2 J dr.); butter, 6 gm. (i^ dr.). 

1. 00 P.M. Egg; sugar, 13 gm. (3 dr.); milk, 142 c.c. 
(4f oz.); cooked chopped chicken, 25 gm. 
(6 dr.); boiled rice, 75 gm. (2§ oz.); zwie- 
back, 10 gm. (2^ dr.); butter, 6 gm. (ij dr.). 

3.00 P.M. I soft-boiled egg; milk, 144 c.c. (5 oz.); scraped 
beef, 20 gm. (5 dr.); boiled rice, 75 gm. 
(2I oz.); zwieback, 10 gm. (2^ dr.); butter, 
6 gm. (li dr.). 

5.00 P.M. Egg; sugar, 14 gm. (3I dr.); milk, 142 c.c. 
(5 oz.); cooked chopped chicken, 25 gm. 
(6 dr.); boiled rice, 75 gm. (2^ oz.); zwie- 
back, 10 gm. (2^ dr.); butter, 6 gm. (i^ dr.). 

7.00 P.M. I soft-boiled egg; milk, 144 c.c. (5 oz.); zwie- 
back, 10 gm. (2i dr.); butter, 6 gm. (i^ dr.). 



320 DIET IN DISEASES OF THE STOMACH 

Thirteenth Day — (Continued). 

Total, thirteenth day, eggs (raw), 4; cooked, 4; milk, 1000 
c.c. (3 3 J oz.); s;ugar, 40 gm. {i\ oz.); scraped beef, 70 gm. 
(2| oz.) ; boiled rice, 300 gm. (10 oz.) ; zwieback, 80 gm. (2| oz.) ; 
chicken, 50 gm. (if oz.); butter, 40 gm. {i\ oz.); calories, 3007. 

Fourteenth Day. 

7.00 A.M. I soft-boiled egg; minced chop; buttered toast; 

milk, 142 c.c. (4! oz.). 
9.00 A.M. Boiled rice; buttered zwieback; custard; milk, 

142 c.c. (4I oz.). 
1 1. 00 A.M. I soft-boiled egg; buttered zwieback; junket; 
milk, 144 c.c. (5 oz.). 
1. 00 P.M. Minced chicken; boiled rice; buttered zwie- 
back; custard; milk, 142 c.c. (4! oz.). 
3.00 P.M. I soft-boiled egg; cooked scraped beef; boiled 

rice; buttered toast; milk, 144 c.c. (5 oz.). 
5.00 P.M. Minced chicken; boiled rice; buttered zwie- 
back; custard; milk, 142 c.c. (4! oz.). 
7.00 P.M. I soft-boiled egg; buttered toast; milk, 144 c.c. 
(5 oz.). 
Total, fourteenth day, eggs (raw), 4; cooked, 4; milk, 1000 
c.c. (33 J oz.); sugar, 40 gm. (ij oz.); scraped beef, 70 gm. 
(2 J oz.); boiled rice, 300 gm. (10 oz.); zwieback, 100 gm. 
(3 J oz.); butter, 40 gm. {i\ oz.); chicken, 50 gm. (if oz.); 
calories, 3007. 

Many patients are unable to take the full amount of food 
ordered after the sixth day, particularly women who may 
have long been small eaters. If pushed, the feedings may result 
in an acute gastric upset, anorexia, nausea, vomiting; in fact this 
has been very frequent in the writer's experience, often making 
it necessary to stop all feedings for twenty-four hours or at 
least after the sixth day only advancing the diet every other 
day, thus giving a little more time to become adjusted to the 
quantity of food. In fact this is the writer's custom whenever 
this form of diet seems indicated. Whenever any hard sub- 
stance like zwieback is called for, it is wiser to substitute a 
little softened toast or even the zwieback softened with hot 
water. 

This diet is probably more successful in acute medical ulcer 
than in either an acute exacerbation of a chronic ulcer or a 
long-standing chronic ulcer. 



PEPTIC ULCER {GASTRIC AND DUODENAL) 321 



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322 DIET IN DISEASES OF THE STOMACH 

Transgastric or Duodenal Feeding.i— This method of feeding 
has been devised by Einhorn and is recommended by him in 
gastric or duodenal ulcer cases or chronic gastric dilatation, 
to prevent weight on the gastric walls and to allow them to 
contract down to more nearly their normal size, this of course 
provided there is no organic obstruction. Also in extreme atony, 
whether there is pylorospasm or not; in cases where nutrition 
is difficult on account of asthenia, absolute anorexia and ner- 
vous vomiting. Einhorn also recommends it in severe Hver 
diseases to reduce the physiological congestion of that organ 
and also in inoperable carcinoma of the stomach where the 
taking of food is painful. 

In gastric or duodenal ulcer with which we are particularly 
concerned here, its usefulness is claimed to lie in the rest, both 
secretory and muscular, which it gives to the stomach and 
possibly to a less extent to the duodenum. 

The duodenal tube is introduced as follows: The tube is put 
in the patient's mouth and he is given a swallow or more of 
water, to wash it down, taking care only that it is not swal- 
lowed too quickly, so that it does not rotate on itself, but will 
go straight into the stomach. The patient then Hes on the 
right side to facilitate the passage of the tube into the duo- 
denum by gravity. This takes a varying amount of time, 
depending on the acidity present, the motor power of the 
stomach muscle and the presence or absence of pylorospasm, 
entering the duodenum quickest in hypoacidity or achylia 
when accompanied, as it usually is, by good muscular action 
and no spasm of the pylorus; the time varying from ten to 
twenty minutes under the latter conditions, to two or three 
hours for normal individuals and even up to thirty-six hours 
at the longest. When the tube is beyond the pylorus it is diffi- 
cult to obtain fluid and what little can be obtained is alkaline 
and usually contains bile. If still in the stomach the fluid 
aspirated by the syringe is of course acid and is in greater 
quantity. If there is achylia and consequently no acid to test 
for,, we can give a little milk or colored fluid by mouth and 
immediately aspirate: if the tube is beyond the pylorus no 
milk will be aspirated. After the tube is once in the duodenum 
it is left there throughout the period of feeding, twelve to 
fifteen days, and the mouth kept clean by frequent use of 
mouth washes. 

The regular feedings recommended by Einhorn consist of 
milk, 7 or 8 ounces, one egg and a tablespoonful of lactose. 
If diarrhea develops the lactose is omitted. Where it is 
necessary to prevent loss of weight or to increase weight 

^ Einhorn: Post Graduate, 19 13. 



PEPTIC ULCER (GASTRIC AND DUODENAL) 323 

I or 2 drams (2-4 gm.) of butter to each feeding may be 
added. Where patients for one reason or another cannot 
take milk, gruels may be substituted but always being sure 
that the feedings are all free from lumps. The number of 
feedings is eight a day at two-hour intervals and must be 
given slowly, taking at least twenty minutes to each; for if 
given rapidly they cause overdistention of the duodenum and 
great discomfort. The best way to introduce the food is by 
means of a syringe with a three-way stopcock so that it need 
not be disconnected each time. 

The food should all be strained and given at body tempera- 
ture and the thinner the tube the more comfortable for the 
patient, although the smaller tubes necessitate slower feed- 
ing. A very important rule is, that after the food has been 
given, a little water, then a little air should be passed through 
the tube to be sure the tube is clean and empty; otherwise 
the tube is apt to be blocked in a day or two, necessitating its 
removal for cleaning. Besides the feedings at least a pint of 
warm normal saline should be given once a day, or this may 
be given by rectum. After the period of transgastric feedings 
is finished one begins mouth feedings with fully peptonized 
milk, then soft thin cereals and gradually increases the feed- 
ings as recommended in the von Leube cure, only one need 
not begin with such small feedings, but the feeding recom- 
mended for the eighth feeding day may be used at the start 
and increased as indicated for that regimen. 

Duodenal Feeding Diet. (Einhorn.) 

7.30 A.M. Oatmeal gruel 180 c.c. (6 oz.) 

One egg 

Butter 15 gm. ( \ oz.) 

Lactose 15 gm. ( \ oz.) 

9.30 A.M. Pea soup 180 c.c. (6 oz.) 

One egg 

Butter 15 gm. ( \ oz.) 

Lactose 15 gm. ( \ oz.) 

1 1 . 30 A.M. Same as at 9.30 a.m. 

1.30 P.M. Bouillon ! . 180 c.c. (6 oz.) 

One egg 

3.30 P.M. Oatmeal gruel 180 c.c. (6 oz.) 

Butter 15 gm. ( \ oz.) 

One egg 

Lactose 15 gm. ( | oz.) 

5 . 30 P.M. Same as at 9.30 a.m. 

9.30 P.M. Bouillon 180 c.c. (6 oz.) 

One egg 

Total amount: Calories. 

Oatmeal gruel 360 c.c. (13 oz.) = 1476 

Eggs 8 = 1352 

Pea soup 720 c.c. (26 oz.) = 384 

Lactose 90 gm. ( 3 oz.) = 369 

Bouillon 360 c.c. (13 oz.) = 39 

Butter 90 gm. ( 3 oz.) = 715 

4335 



324 DIET IN DISEASES OF THE STOMACH 

Diet Combined with Alkaline Treatment. — There have been 
advanced many forms of the alkaline treatment combined 
with proper diet for cases of gastric and duodenal ulcer, but 
apparently the one most specifically and carefully worked out 
for this is the treatment arranged and practised by B. W. 
Sippy^ of Chicago. By this method he feels that an operative 
procedure is scarcely ever necessary, as the cases are so regu- 
larly cured by medical means, and he even includes all cases 
of pyloric stenosis, except those of extreme narrowing, due to 
definite cicatricial contraction following a healed ulcer. He 
says that after three, four or more weeks of this treatment 
the spasm is relieved, the round-celled infiltration disappears 
as well as the edema of the inflammatory tissues, and the 
lumen is again established so that in practically every case a 
motor meal, consisting of meat and vegetables, leaves the 
stomach within the normal limits of six or seven hours. This 
is of course, quite radical and might be considered an extreme 
statement; Sippy, however, is most definite in his statements 
as to methods, what is to be expected and the results obtained, 
and since they are made on such responsible authority they 
warrant a respectful hearing and a very thorough trial in 
practice. He limits surgical interference in ulcer cases to the 
following conditions and complications. 

1. Perforation. 

2. Perigastric abscess. 

3. Secondary carcinoma. 

4. Hour-glass or other deformity. 

5. Hemorrhage of a serious nature under certain conditions. 

6. Pyloric obstruction of high grade not influenced by 
medical treatment. 

The underlying principles on which the diet and treatment 
are founded may be stated as follows: Peptic ulcers would 
tend to heal spontaneously, as ulcers situated elsewhere, were 
it not for the fact that they are constantly subjected to the 
corrosive action of the gastric juice and that if this can be 
neutralized continuously during the period of gastric and upper 
intestinal digestion by proper diet and alkalis and the removal 
at night of any product of continuous hypersecretion, the ulcer 
will heal without diflliculty. With this as a basis, Sipp}^ treats 
and diets these cases as follows: 

Patients are put to bed for from three to four weeks, at the 
end of which time they are gradually allowed up and out as 
one would after any illness of a corresponding length, but no 
real work should be attempted for a period of seven or eight 

^ Sippy, in Musscr and Kelly: Jour. Am. Med. Assn, 1915, Ixiv, 20, 1625. 



PEPTIC ULCER (GASTRIC AND DUODENAL) 325 

weeks at least. As originally outlined the initial treatment 
consists of a period of five days in which no food or drink was 
given by mouth, but about 12 ounces, more or less, of saline 
was given by rectum four times a day. Subsequently, this 
period of starvation was abandoned, and presumably, except 
in the case of severe hemorrhage, the feedings were begun at 
once. Each morning one-half hour before the first feeding a 
dram of subnitrate of bismuth is given in a little water. Feed- 
ings are given every hour from 7 a.m. to 7 p.m., consisting of 
equal parts of milk and cream in amounts of a total of i to 3 
ounces. Although acidity is more easily controlled by hourly 
feedings, some cases do well on two, three or four hourly feed- 
ings. Half-way between each feeding a powder consisting of 
10 grains each of calcined magnesia and sodium bicarbonate 
is given, alternating with another powder of 10 grains of bis- 
muth and 20 to 30 grains of soda bicarbonate. It is best to 
give the powder containing magnesia as often as possible as 
the magnesia has four times the power of neutralizing the free 
hydrochloric acid as compared with the soda; diarrhea, how- 
ever, is apt to follow its free use, so that one must alternate 
these powders according to this condition. After two or three 
days, soft eggs and well-cooked (fine) cereals are added so that 
at the end of about ten days the patients are receiving the 
3 ounces of milk and cream mixture every hour from 7 a.m. 
to 7 p.m., 3 soft-boiled eggs, one at a time, and 9 ounces of 
cereal, 3 ounces given at each of three feedings. These extras 
are added one at a time until the six extra feedings of eggs 
and cereals are given evenly s'j^aced throughout the day. The 
bulk of each feeding should not exceed a total of 6 ounces. 
In order that the treatment should be successful, an accurate 
control of the acidity must be maintained throughout the 
twenty-four hours. This is accomplished by testing the gas- 
tric contents from time to time, early in the treatment, by the 
stomach-tube (or Einhorn's duodenal tube may be used to 
advantage, as very easy of application). Sippy's method for 
accurate control of the free hydrochloric acidity is somewhat as 
follows: the first day or two the tube is passed occasionally to 
check up the presence of free HCl; if present in the stomach 
contents the alkali powders must be increased, as the treatment 
aims absolutely to keep the free HCl down to zero. After a 
day or two this is done as a routine two or three times a week, 
as practically that is all that is necessary to insure the absence 
of the hydrochloric acid. 

The amount of alkali can be varied as determined by the 
examination of the stomach contents. It is particularly neces- 
sary to be sure that the stomach does not contain free acid 



326 DIET IN DISEASES OF THE STOMACH 

during the night and it may be necessary to give two or three 
alkaH powders between 7 and 10 p.m. to insure this. At 10 
o'clock the tube should be passed and all acid hypersecretion 
removed. If there is a considerable amount of this, the tube 
should be passed again during the night two or three times. 
After the first few days' treatment this is rarely necessary as 
the hypersecretion is usually well controlled and at 10 p.m. 
noth ng but a very few c.c. of gastric contents are found which 
are unimportant. 

In the diet, cream soups, vegetable purees or other soft 
foods may be added or substituted, such as jellies, custards, 
creams; keeping, however, the milk, cream, eggs and cereal as the 
basis of the diet. The best cereals are farina, cream of wheat, 
rice cooked to a soft pulp. With this diet it is quite regularly 
that the cases, according to Sippy, show a gain of from i to 
4 pounds a week. 

During the third week, soft toast or crackers, puree of 
potato, cream soups may be added. In the fourth week the 
milk and cream may be made 2| ounces each at each feeding 
and the period between feedings lengthened to two hours. 
After two or three weeks more, three-hour feedings may be 
given, but if the ulcer is of some months' duration it is best 
not to increase the periods too rapidly and for several months 
it is wise not to have the patients take less than five feedings 
a day. The morning bismuth should be taken for from six to 
eight weeks and then stopped and the alkaline powders should 
be continued between feedings for several months. 

^^During a period of a year or more, milk, cream, eggs, vege- 
tables, purees, cereal, bread and butter and meats should form 
the basis of the diet." In cases that for one reason or another 
milk is distasteful, it often can be given if flavored with tea, 
cocoa, grape juice, etc., frozen balls of butter may be substi- 
tuted for cream and a small quantity of cereal gruel may be 
given each hour. 

Ambulatory Diet Cure for Peptic Ulcer. — There are always a 
certain number of cases that are seen in whom the symptoms 
are very suggestive of chronic ulcer, but in whom the diag- 
nosis is not sufficiently certain or for one reason or another 
the patients will not or cannot give the time for a regular 
course of treatment in bed. In these cases it is advisable to 
put them on a bland diet which has sufficient food value to 
keep up the patient's strength, and combine well with the 
usual large excess of free hydrochloric acid and be obtainable 
almost any and everywhere. In this day of the **dair3" lunch," 
it is very easy to obtain this diet anywhere about a city. If 
the case is actually one of gastric or duodenal ulcer the chances 



DIET AFTER HEMORRHAGE FROM STOMACH 327 

are very great that at least there will be decided temporary 
relief, sometimes for a year or more and in a few cases, partic- 
ularly if persisted in for three or four weeks, the writer has 
seen cHnical cures. The diet is also of considerable diagnostic 
value, as the case which is clinically ulcer but does not get very 
great or complete temporary relief for weeks or longer, is very 
probably not ulcer but chronic appendicitis, gall-bladder dis- 
ease or something else which simulates ulcer. 

The diet for these ambulatory cases is planned as follows: 
For two (or more) full weeks, they take at 8 a.m., i and 7 
P.M., 2 glasses of milk (f cream) and 2 soft-boiled eggs (i min- 
ute), without salt at first. At 11 a.m., 4 and 10 p.m., i\ 
glasses of milk (J cream). This contains milk, 84 oz. (2520 c.c.) ; 
cream, 16 oz. (480 c.c); eggs, 6. 

The food value of this diet is approximately: Protein, 151 
gm. (5 oz.); fat, 246 gm. (8.2 oz.); carbohydrate, 122 gm. 
(40Z.); calories, 3080. 

After the two weeks are up, or longer in severe cases, one can 
add fine well-cooked cereals, custards, gruels, cream soups, 
soft toast; later boiled fish, etc., as in the third and fourth 
weeks of the von Leube diet. . 

One does not expect to get the best results with this diet 
and it should not be advised unless the patient refuses for 
one reason or another to take a full course of diet with rest 
in bed. Vichy is the best form in which to take water between 
feedings or if more alkali is indicated by much acidity. Alkali 
powders may be given an hour to an hour and a half after 
the principal feedings. If the milk mixture does not seem to 
agree, some of the alkali may be added directly to each feed- 
ing.^ An occasional case has to omit the cream on account of 
increased gastric acidity. 

DIET AFTER HEMORRHAGE FROM STOMACH OR 
DUODENUM 

At the first evidence of hemorrhage the patient is to be 
kept absolutely at rest and quiet in bed. If the hemorrhage 
is severe so that Hfe is threatened either from exsanguination 
or cerebral anemia, the foot of the bed should be elevated on 
shock blocks and the patient's limbs tied oflT with broad ban- 
dages to keep as much blood in the trunk and head as pos- 
sible. Each limb should be left tied off not longer than ten 
minutes at a time, they can be used thus in rotation, one or 

^ A very good form of alkaline powder to use is equal parts of soda bicarbonate, 
heavy burned magnesia and subnitrate of bismuth. Bismuth subnitrate in dr^m 
doses is useful to control pain when given on an empty stomach early in the 
morning. 



828 DIET IN DISEASES OF THE STOMACH 

two at a time. Absolutely nothing should be given by mouth, 
not even cracked ice, but if there has been great loss of blood, 
saline may be given by rectum either in 4- to 6-ounce amounts, 
every three or four hours or by continuous Murphy drip. If 
the hemorrhage is extreme a saHne infusion may be given or 
better still a blood transfusion from a suitable donor. If the 
hemorrhage is recurring and too excessive, the question of 
immediate laparotomy must be considered. 

After hemorrhage, it is best, if possible, not to use rectal 
saline or feeding for at least twenty-four to forty-eight hours 
unless the thirst becomes too excessive. The chief reason is, 
that anything put into the rectum starts antiperistalsis which 
may reach the stomach, and also that it is capable of starting 
gastric secretion. After this period is past one may begin on 
one of two lines of treatment. 

1. Feeding by rectum entirely, for from two to Rve days, 
or even longer and then begin on the Lenhartz or von Leube 
diets. 

2. By beginning at once with a Lenhartz or von Leube 
diet, as already explained. In the author's opinion the Len- 
hartz is better suited to acute ulcerative conditions than to 
chronic, while the von Leube, particularly as modified by 
Lockwood, is better for either condition, acute or chronic. 

From this point the diet is arranged in accordance with the 
details of the diet selected. Practically all clinicians of experi- 
ence favor at least a period of twenty-four to forty-eight hours' 
absolute rest to the stomach before food or even water is 
given by mouth. 

GASTRIC ATONY. 

(Impaired Gastric Motor Function or Myasthenia 

Gastrica.) 

Enough has been said of this condition of atony when com- 
plicating chronic gastritis to indicate quite fully the principles 
involved in prescribing a dietary for use in patients suffering 
from motor insufficiency of the stomach. 

Since the condition is almost always secondary to a general 
muscular and nervous debility often found in patients after 
exhausting or long-continued disease, and in those of enterop- 
totic habitus, the greatest care must be exercised in choosing 
a diet in order to overnourish these patients, if possible, so that 
they can gain in general ways, while at the same time prevent- 
ing gastric overdistention and the introduction of foods which 
leave the stomach slowly or with difficult}^, such as all coarse 
or tough foods, heavy fats, etc. 



GASTRIC ATONY 329 

Many patients with motor insufficiency of the stomach get 
fixed ideas as to what they can or cannot eat and since it is 
usually the latter, they very quickly add to their troubles 
marked malnutrition and eventually settHng down to a dietary 
which is hopelessly inadequate to nourish them, with the 
result that their stomach musculature becomes still further 
weakened. 

Motor insufficiency has been termed. by some authorities as 
"an indigestion of liquids" which simply means that liquids 
remain in the stomach longer than solids in this condition, so 
giving rise to fulness, splashing and regurgitation for a longer 
or shorter time after the stomach should be normally empty. 
It must also be kept in mind that many if not most of these 
patients show general improvement, when on a proper diet, a 
considerable time before the gastric muscle regains its tone 
and they are constantly tempted to break rules and eat or 
drink as they choose because they feel so much better and 
stronger; only a firm adherence to diet and general hygiene 
with graduated exercises will bring the desired result with a 
return to normal of the gastric functions. Associated with 
the myasthenia one finds very frequently a condition of gas- 
tric hyperacidity which must also be taken into consideration 
in the diet planned for these individuals, also many persons 
with congenital or acquired ptosis of the stomach show the 
same combination of pathological conditions, namely, myas- 
thenia and hyperacidity, either separately or combined. 

General Directions in Gastric Atony. — Before touching 
directly on the foods best suited to these cases it would be worth 
while to formulate certain rules for these patients to follow, 
which will aid the stomach in performing its motor functions 
with the greatest efficiency under the individual circumstances. 

1. Patients should always have a period of absolute rest 
before meals, recHning for fifteen to thirty minutes. It is 
astonishing how much this rest will improve the appetite and 
muscular tone, it means that they eat when rested and do not 
hurry in to a meal from some occupation; this is one of the 
greatest aids to good digestion in any abnormal condition of 
the gastro-intestinal tract. 

2. Meals should be small, well-cooked and of easily digested 
materials, rather dry and of concentrated caloric value, with- 
out skins of fruit and vegetable seeds, gristle or fat which does 
not melt at body temperature, e. g., mutton fat. 

3. The interval for feeding in severe cases should be every 
three hours; 3 or 4 ounces or more of water should be given 
three-quarters of an hour before meals, best at room tempera- 
ture or warm, never cold. 



330 DIET IN DISEASES OF THE STOMACH ' 

4. At meals it is best to take no liquids or at most not over 
3 ounces and then only in the less severe cases. 

5. It should be remembered that milk often fails to agree 
with these patients, increasing flatulence. 

6. After meals when possible and always in severe cases, 
patients should lie for half an hour to an hour on their right 
side in order to facilitate evacuation of the stomach by gravity. 

7. Many cases, particularly those complicated by gastro- 
ptosis will get great digestive benefit by wearing a proper cor- 
set or belt. This helps to fix a usually flabby abdominal wall 
and improves the splanchnic circulation, often resulting in a 
general increase of the systolic blood-pressure; such patients 
often having an abnormally low arterial tension, 85 to 100 
mm. Hg. 

8. Other hygienic measures useful in this condition will be 
found in books dealing with this particular subject, e. g., 
exercises, bathing, sleep and rest. 

Keeping in mind the foregoing rules it would hardly seem 
necessary to give a specimen dietary for such a case, but many 
are too busy or lack enthusiasm for these details, hence the 
following sample diets are given with the caution that such con- 
ditions as hyperacidity or hypoacidity, fermentation, pyloric 
spasm, etc., must be recognized if present and due allowance 
made in the selection of a diet (see special rules for diet in 
hyper- and hypoacid gastric conditions). 
Diets for Atony: 
7 A.M. 2 tablespoonfuls of any well-cooked cereal with 
butter and sugar (heavy cream if it agrees). 
Bread or toast and butter, two slices; i soft- 
boiled egg. 
10 A.M. Custard (unsweetened) with cream, 2 or 3 toasted 
saltines. 
I P.M. Chopped meat or chicken or fish; bread and but- 
ter; rice, cooked to a pulp, with butter and salt, 
or beef juice or baked potato. Later a small 
portion of baked hubbard squash, stewed celery, 
or rice or bread pudding, but both dessert and 
vegetables should not be taken at the same meal. 
4 P.M. Cream cheese with toasted and buttered saltine 

biscuits, as a sandwich, one or two of these. 
7 P.M. Fish or eggs (except fried), bread and butter; rice 
with butter and cream, a simple dessert, such as 
custard, blanc mange, Spanish cream, etc. 
10 P.M. Same as 10 a.m. or 4 p.m., feedings or a plain sand- 
wich made of beef, chicken or mutton; Swiss 
cheese, bread and butter. 



GASTRIC ATONY 331 

For those who can take milk, it may be used in* various 
ways, plain buttermilk or junket, etc. Many of these cases 
of myasthenia being merely a part of a general neurasthenia 
with malnutrition, do well on the Wier-Mitchell rest cure 
routine, care only being taken that large quantities of food 
shall not be taken at one time. In the severe cases it is often 
best to feed every two hours instead of every three, using 
small feedings of concentrated nourishment, then gradually 
increasing, the intervals of feeding and the quantity of food at 
each feeding. 

Diet for Severe Atony: 

8 A.M. Junket, 240 c.c. (8 oz.), with cream, 60 c.c. (2 oz.). 
II A.M. 4 saltines, with cream cheese. 

I P.M. Sandwich of bread and beef. 

4 P.M. Cocoa, junket, 360 c.c. (12 oz.). 

7 P.M. Custard, baked or boiled, 180 gm. (6 oz.). 

9 P.M. Sandwich, with chicken and bread. 
Wegele's Diet for Atony of the Stomach: 

Morning. — Dry toast, 30 gm. (i oz.); a cupful of cocoa made 
of leguminose cocoa and 60 gm. (2 oz.) of cream. 

Forenoon. — An egg (poached or soft-boiled) and 30 gm. (i oz.) 
of toast. 

Midday. — Scraped meat, 100 gm. (3! oz.); mashed potato, 7 
oz. (210 gm.); toast, 30 gm. (i oz.); followed by 30 gm. (i oz.) 
of extract of malt. 

Afternoon. — A cupful of cocoa with 60 c.c. (2 oz.) cream. 

Evening. — Tapioca cooked to a pulp, 300 gm. (10 oz.). 
Followed by 20 c.c. (f oz.) of malt extract. 

10 P.M.— -A tumblerful of milk with a dessertspoonful of 
cognac brandy. 

Tibbies,^ on the other hand, recommends only three meals 
at 8 A.M., 2 P.M. and 8 p.m., two of them mainly protein, giving 
most of the carbohydrate at midday, as follows: 

Breakfast, 8 a.m. — Fish (sole, haddock, weakfish, sea bass, 
halibut), with a little lemon juice; i or 2 eggs, poached or 
lightly boiled. A small amount of crisp dry toast or stale 
bread, and a cupful of coffee with cream and one piece of 
sugar. 

Midday. — 2 p.m. (No meat.) Boiled macaroni with a trace 
of grated cheese or boiled rice with tomato, puree of cabbage, 
savory or potato with gravy or extract of meat; boiled spinach, 
vegetable marrow or squash, string or snap kidney beans. 
Any milk pudding which has been cooked slowly (four or five 
hours). Jellies or creams made with gelatin, or fruit jelly or 

^ Tibbies: Dietetics, Lea & Febiger, p. 295. 



332 DIET IN DISEASES OF THE STOMACH 

cooked apples, plums, prunes and raw fruit rubbed through a 
sieve (raspberries, strawberries, blackberries or currants). At 
the end of the meal 4 or 5 ounces of water, diluted spirit,, 
Burgundy or Bordeaux. 

Evening. — 8 p.m. Soup about 90 c.c. (3 oz.); fish (same as at 
breakfast), tender lean beef or mutton, poultry, venison,, 
pheasant or other game (except hare); 30 gm. (i oz.) of potatO' 
puree or boiled rice or toast or stale bread; no pudding or 
dessert. At the end of meal 2 glasses of wine or 30 c.c. (i oz.) 
of whisky in 120 c.c. (4 oz.) of water. The food has a heat 
value of 2150 calories and contains: 

Protein. Fat, Carbohydrates. Alcohol. 

209.6 gm. 58.7 gm. 142.5 gm. 35 c.c. 

Diet for Mild Atony :^ 

8 A.M. Cup of coffee or cocoa, with cream, sugar, fine cereal. 
II A.M. Egg shake, Russell's Emulsion or koumyss. 

I P.M. Steak or chop, one vegetable, rice pudding, bread 
and butter. 

4 P.M. Chicken sandwich and a glass of hot milk. 

7 P.M. Fish or chicken, two green vegetables, tapioca 

pudding. 
For advanced atony, still smaller meals are best, e. g.: 

8 A.M. Cup of coffee or cocoa with cream, sugar; soft- 

boiled egg, bread and butter. 
II A.M. Baked custard. 
I P.M. Minced chicken on toast, cornstarch pudding. 
4 P.M. Scraped beef sandwiches. 
7 P.M. Small broiled chop, creamed spaghetti. 
10 P.M. Cup of malted milk. 

The same rules in regard to drinking as before outlined. 
Meals should be dry, never more than one glassful of fluid and 
better less, half a glassful between meals once or twice. 

ORGANIC GASTRIC ACIDITY. 

This may be of two sorts, one due to the ingestion of organic 
acids in foods, such as acetic acid in pickles, cider, vinegar or 
acid-wine preparations; butyric acid from butter, lactic acid 
from buttermilk or other fermented or ripened milks. The 
other form of organic acidity is that due to the development of 
acids arising in the process of gastric fermentation, thus lactic 
acid from bacterial action on carbohj^drates, butyric acid 
from dextrose and in fact any sugar, also from lactic acid. 

^ Lockwood: Diseases of the Stomach, p. 327. 



CARCINOMA OF STOMACH 333 

When gastric hydrochloric acid acidity is normal, bacterial 
activity is checked and organic acids are not found in the 
gastric contents unless they are ingested, except in minimal 
amounts. 

The dietary treatment of organic acidity depends, of course, 
first on the prevention of the ingestion of the acids and then 
upon the omission from the diet of acid-forming bodies, such 
as wines, butter, sugar and starches. At times it is best to 
put the patient on a milk diet for two or three days, then to 
add eggs, meat, fish, green vegetables and fruits, but omitting 
all farinaceous foods for a time. When all symptoms have 
subsided, well-toasted bread or cereal food may be allowed 
once a day, then twice a day, and later three times a day and 
so on until the patient is back to a full mixed dietary. 

CARCINOMA OF STOMACH. 

The presence of a cancerous growth anywhere in the body 
is a guarantee that sooner or later the patient's nutrition will 
suffer and in spite of a sufl&cient intake these people lose weight 
out of apparent proportion to the size of the growth or indeed 
its location. To this rule there are numerous exceptions and 
all clinicians are familiar with the latent type of carcinoma 
that develops silently without giving the usual outward signs 
of nutritional disturbance until toward the end of the course 
of the disease. Some of these cases maintain a remarkable 
degree of nutrition up to the end, but of course, most of them 
lose very rapidly as the disease progresses and the emacia- 
tion in long-standing cases, particularly where the digestive 
tube is involved, is often extreme. The toxic destruction of 
tissue protein keeps a negative nitrogen balance in spite of a 
high protein intake and when the amount taken is below the 
average normal, the emaciation is especially rapid. 

The partial or complete failure of free hydrochloric acid in 
the gastric secretion is a usual accompaniment of gastric car- 
cinoma at some time in the course of its development, although 
it may not be evident in the earHer stages, but what is often 
lost sight of, is the fact that this same hypoacidity may be 
present, when carcinoma is present at some point remote 
from the stomach. This fact has in all probability much to 
do with the disturbances in digestion, as the lack of normal 
gastric secretion results not only in the lessening of gastric 
digestion but the normal stimulus for the pancreas and intes- 
tine is diminished or wanting and so the normal preparation 
of food-stuffs for absorption is interfered with, the results of 
which soon become evident. 



334 DIET IN DISEASES OF THE STOMACH 

Diet in Carcinoma of the Stomach. — The diet suitable for 
this disease depends principally upon the complications which 
may be present, and there are some fundamental facts which 
must be kept in mind. 

1. These cases of carcinoma on account of the hypoacidity 
should be given only moderate amounts of meat products, 
unless there are other further contra-indications. 

2. The gastric motihty is apt to be disturbed with delayed 
emptying of the stomach, particularly in the later stages, when 
this is present, it is necessary to diet according to the rules 
laid down for myasthenia gastrica (atony). 

3. When ulceration is evident one must be governed some- 
what by the principles advised for a peptic ulcer diet, in that 
the foods should be soft and non-irritating. It is not neces- 
sary to reduce the quantity except in the presence of rather 
extreme ulceration, for there is no chance of healing a carci- 
nomatous ulcer by diet, and it is most important to keep up 
the patient's nutrition to as high degree as possible, so these 
patients should be fed to the limit of their capacity with 
suitable liquids, semiliquids and soft foods. 

4. Where ulceration is extreme or the anorexia so severe 
that nutrition is interfered with out of proportion to the devel- 
opment of the growth, good results may be obtained by duo- 
denal feedings, using liquid foods of high caloric value, as 
suggested under the chapter on Duodenal Feeding (p. 322). A 
fair amount can be done in this way to maintain the patient's 
weight and strength. 

The use of an early morning saline drink is especially good 
both for the cleansing effect on the gastric mucous membrane 
and for a laxative effect when this is necessary. Those waters 
with sodium chloride are good for their cleansing effect, par- 
ticularly as there is usually an absence of chlorides in the 
stomach. Weisbaden or Carlsbad sprudel represent the two 
types, Weisbaden that without laxative effect and the Carls- 
bad when a laxative effect is needed. For most cases Vichy, 
either French or artificial, 4 ounces, does very well, or failing 
this, the use of 20 grains of soda bicarbonate and 10 grains 
of common salt in 6 ounces of water answers every purpose, 
with the addition of sodium sulphate or phosphate when addi- 
tional laxative effect is desired. 

Most of these patients crave food more highl}^ seasoned than 
usual and there is no objection to this within reason. 

In the apparent absence of ulceration alcohol should be 
taken only sparingly on account of its tendency to disturb 
digestion. As an appetizer with meals, a little diluted wine 
or whisky finds no contra-indication in fact unless, again, 



CARCINOMA OF STOMACH 335 

ulceration is present. Foods that irritate or ferment readily 
should not be taken and are hardly likely to be, as anorexia 
is often a prominent symptom. 

When the growth involves either the cardia or pylorus, 
after a time only liquid food will pass a stricture. This food 
should be chosen with a view to its concentration as well as 
its fluid consistency and to this end milk, cream and lactose 
mixtures, with gruels made from cereals, pea soup with con- 
siderable amounts of butter, or puree soups in which cream is 
a large ingredient, and with ice-cream, made with eggs and 
liberally sweetened with lactose must form the bulk of the 
diet. In the preparation of milk to be used in the presence of 
pyloric stenosis, it is well to boil it first then flavor it with 
cocoa, coffee, tea, etc., as boiling causes the curd to be fine 
and soft and to oflPer less diflficulty in passing the pylorus. 
This is a necessary precaution, as even in the absence of normal 
gastric digestion whole milk will curd from what little acid 
there may be present, but the further chymification is inter- 
fered with on account of the diminished hydrochloric acid and 
pepsin, so that the thick curd may remain in the stomach an 
indefinite length of time. Adding i or 2 grains of sodium 
citrate to each ounce of milk has the eff'ect also of preventing 
the formation of any but light, flocculent curds. 

The liquid beef preparations are good as appetizers and for 
their stimulant eflFect, but their food value is so small that 
one must not be deceived by their bulk in thinking that any- 
thing of great food value is being given. The malted milk or 
dried-milk preparations are good to use for the sake of variety, 
but after all, the more normal the constituents of the diet can 
be kept the better the appetite and nutrition will be preserved. 
Any one of the predigested proteins is good to use. 

In the presence of hemorrhage, unless excessive, it is not 
wise to stop food for more than a few hours, although the qual- 
ity and quantity of food taken afterward might better conform 
for a time to one of the peptic-ulcer diets, but as already 
stated, in connection with severe ulceration, the quantity must 
be rapidly advanced after a day or two of semistarvation, 
otherwise the loss of flesh and strength will be out of propor- 
tion to the uncertain improvement in the pathological condi- 
tion present. 

When the pain from ulceration is so great as to cause great 
distress on the ingestion of food, it is well to give the patient 
a 5-grain orthoform tablet to dissolve in the mouth before 
meals or a small amount of cocaine in solution may be given, 
I or 2 grains, but this should not be done regularly. Anes- 
thesin, 2 per cent., in olive oil may be given in |-dram doses 



336 DIET IN DISEASES OF THE STOMACH 

before meals, or bits of cracked ice with or without a Kttle 
eHxir of menthol^ may add greatly to the patient's comfort, if 
given before feedings. When the cancerous condition reaches 
this stage it is of course best to keep up a certain amount 
of morphine regularly, and the question of gastrostomy or gastro- 
enterostomy must be considered as a temporizing measure. 
The rehef to certain cases from these operations is, at times, 
exceedingly great, depending on the anatomical condition 
present, often permitting the patients to gain weight and a 
certain amount of well-being which may last several months 
before they finally succumb to the disease. When all else fails 
resort may be had to rectal feeding, but this, as already pointed 
out in the chapter on artificial modes of feeding, is inadequate 
in furnishing sufficient food to maintain life for any consider- 
able length of time, except at a low ebb, and acts as little 
more than a placebo, although sufficient fluid can be given to 
prevent great thirst and desiccation. 

GASTRIC DILATATION. 

In considering the question of gastric dilatation one natu- 
rally divides the condition into an obstructive and non-obstruc- 
tive variety and again into an acute and chronic type. 

In the acute form whether from obstruction, such as an 
arteriomesenteric constriction, in very thin individuals, or 
obstruction due to acute kinking of the duodenum, or that 
due to paralytic causes, either central or peripheral, of which 
postoperative or postanesthetic, overdistention or toxic are 
the chief varieties, ^ the treatment is identical and so far as 
diet goes is quickly written. Give nothing whatever by 
mouth, neither food nor water. The former is not needed for a 
time and the latter may be supplied by rectal salines, or if 
necessary by hypodermoclysis. Lavage every two or three 
hours to remove the accumulated fluid with proper postural 
treatment with the patient lying well over on the right side 
or on the stomach are the forms of treatment needed. After 
it is seen that the dilatation has subsided and one no longer 
gets the characteristic brownish fluid by the stomach-tube, 
one can begin to feed small amounts of peptonized milk or 
gruel, gradually increasing the amount of food and the qualit}^ 
from fluid to semisolid and then to soft until after a period 
of three or four days to a week one can return to soft solid 
food, provided the general condition of the patient warrants it. 

1 Elixir of menthol: Menthol i.o, Spts. Vin. 25.0, Aq. destil. and Syr. simpl. 
aa 12.0. 

2 Lockwood: Diseases of the Stomach, p. 335. 



GASTRIC NEUROSES 337 

In the chronic forms of dilatation, if this is due to obstruc- 
tion at the gastric outlet, one usually finds a good gastric 
muscle tonus, in fact it is often hypertonic, as the visible peris- 
taltic waves testify; but the difficulty is that the outlet is 
more or less narrowed so that first, heavy coarse articles of 
food fail to pass the obstruction, then later ordinary mixed or 
soft food cannot leave the stomach completely and stagnates, 
until finally, in the more advanced stage, even liquids cannot 
pass the pylorus. Of course before one considers dietetic 
treatment an accurate diagnosis is necessary for any intelli- 
gent mode of action. Having determined the degree of sten- 
osis one gives a diet suitable for the underlying cause whether 
it be ulcer or simple cicatricial stenosis of varying degree. In 
the latter, if moderate, only sqft diet finely divided, milk 
citrated to prevent a heavy curd (i grain sodium citrate to the 
ounce of milk) or boiled to the same end, may be given, with 
lavage at bedtime to prevent stagnation. In the more 
advanced cases when only fluids will pass one can use fully 
peptonized milk, puree soups, cream soups with butter and 
meat extract or meat jelly. Of course in such an instance of 
extreme stenosis, operative procedure must be contemplated 
and decided upon before the patient loses vitality and strength. 
If Sippy's claims are substantiated most of the cases due to 
ulcer and round-celled inflammatory exudate recover without 
operation on the diet as outlined by him (see p. 324). Where 
the chronic dilatation is secondary to a general or gastric 
myasthenia the diet must be in accordance with that laid down 
for the dietetic treatment of atony (p. 330), and the principles 
of small dry meals with total reduction of fluid during the 
twenty-four hours to one quart, or at times less, must be 
adhered to. Certain authors recommend in this condition small 
feedings of concentrated soups, frequently repeated and this plan 
may be followed if that already referred to does not succeed. 

The acute form of dilatation is most satisfactory to treat if 
recognized early, the chronic form most- unsatisfactory as a 
rule, for if the dilatation is due to an actual obstruction, 
although the diet may be modified as already explained to 
meet varying degrees of stenosis, the time eventually comes 
in practically all cases when the case becomes a surgical con- 
dition (if indeed it is not from the beginning), and an operation 
imperative. 

GASTRIC NEUROSES. 

The forms which gastric neuroses can take are many, but 
they group themselves naturally about disturbances in — - 
I, secretion; II, sensation, and III, motility. 



338 DIET IN DISEASES OF THE STOMACH 

The neuroses play a much smaller role in diagnosis than 
they formerly did, since we have come to know that many 
conditions previously considered neuroses have a definite 
pathological basis, that, for example, Reichman's disease or 
continuous gastric secretion can no longer be placed with the 
neuroses but is due to some form of chronic irritation along 
the gastro-intestinal canal, and is perhaps most frequently 
associated with chronic gastric or duodenal ulcer. So too, if 
one considers the so-called neuroses of sensation we find it 
necessary to recast most of these diagnoses and the persistent 
gastralgia formerly classed as a neurosis is now known to 
betoken real trouble in practically every instance, due to 
chronic ulcer, appendicitis or gall-bladder disease in most 
instances. So it goes throughout the entire fist; nevertheless 
there are some real digestive neuroses left belonging to all 
three classes which require attention, medically and dieteti- 
cally. 

Secretory Neuroses. — By far the greatest number of these 
cases have an excess of secretion, particularly of hydrochloric 
acid. This gives rise to nervous hyperchlorhydria with its 
attendant symptoms of acid eructation, belching, constipa- 
tion, .etc., all coming on at times of stress when the nervous 
system is overirritated, as for example in students preparing 
for examination, young speakers and actors. Even in these 
cases if there is continued repetition of the symptoms one 
must be on the lookout for a pathological basis. The diet here 
should be that described for hyperchlorhydria, avoidance of 
all irritants must be insisted upon, such as: chemical, e. g.y 
acids, alcohol and condiments; mechanical, e. ^., seeds or hard 
substances; thermal, e. g., hot or iced drinks or foods; and as 
well, food should be simply prepared, eaten slowly at regular 
intervals and with full attention to proper methods of eating. 
The general hygiene of the nervous system should also receive 
attention (see Hyperchlorhydria). Excessive secretion may 
at times be purely nervous, but continuous secretion is usually 
of pathological significance. 

In other cases the neurosis takes the form of a hypoac dity 
even to an achylia gastrica which has been supposed at times 
to be of nervous origin, although probably even in man}^ of 
these an anatomical basis may be found. The diet for this 
should be that advised for hyposecretion or achylia gastrica 
(see p. 304) and in general should be stimulating but not 
irritating. 

Neuroses of Sensation. — All sorts of morbid gastric sensa- 
tions may be felt by the neurasthenic, ranging from merely a 
sense of uneasiness or fulness to actual pain, the latter, how- 



GASTRIC TEST MEALS 339 

ever, as already stated if persistent or recurring is almost 
always due to some pathological state of the digestive tube 
itself and is not a neurosis. The treatment here should be 
of course, largely along neurological lines,, the diet must be 
full, simple and nutritious and if the symptoms occur in 
patients (especially women) who are thin, and so to speak 
"on wires" nervously, they should be put to bed and given 
the rest cure regimen, such as that devised by Wier Mitchell 
or some modification of it. The digestive symptoms usually 
disappear within the first week of this routine. 

Motor Neuroses. — Many of the abnormal sensations included 
under this last group are due to a nervously disturbed gastro- 
intestinal musculature, giving rise to peristaltic unrest which 
in a normal state passes unnoticed, but which loom large to the 
nervous person. Another and familiar form of motor disturb- 
ance is seen in nervous vomiting which is often so difl&cult 
to control. All these forms of motor neuroses must be treated 
first from a general hygienic and neurological point of view by 
hydrotherapy, suggestion, etc., diet may often be ignored and 
in many instances if we can gain the patient's confidence they 
can often be told to eat anything they want and it will many 
times be found that such seeming indulgence works wonder- 
fully well, anything within reason being digested. At other 
times one must treat these cases as one does a stomach which 
is irritable from some pathological cause, for often a digestive 
organ that has been misbehaving for a long time develops a 
secondary irritation which is real and must be definitely treated 
by a diet that is useful in any irritable stomach, e. g.y fluids, 
as milk and Vichy or buttermilk and Vichy, egg albumen in 
cracked ice and water, iced bouillon, iced malted milk, gruels, 
thin soft solids, cereals, custards, blanc mange, soft eggs, cream 
toast, back to solids with white meat of chicken, baked farina, 
vermicelh, noodles and by degrees to a normal dietary. 

GASTRIC TEST MEALS. 

Ewald-Boas Test Breakfast. — Water, 400 c.c. (13 oz.); bread 
or roll, 40 gm. (ij oz.). Given on an empty stomach. 
Expressed by aspiration one hour later. 

Ewald Test Dinner. — Chopped meat 165 gm. (6 oz.); stale 
bread, 35 gm. (i oz.); butter. Aspirate three hours afterward. 

Test Meal of Germain, See. — Chopped meat, 100 to 150 
gm. (3 J to 5 oz.); white bread, 60 to 80 gm. (2 to 2f oz.); 
water, 300 c.c. (10 oz.). Examine contents two hours later. 

ReigeFs Test Dinner. — Meat broth, 400 c.c. (13 oz.); beef- 
steak, 150 to 200 gm. (5 to 7 oz.); mashed potato, 50 gm. 



340 DIET IN DISEASES OF THE STOMACH 

(if oz.); roll, 35 gm. (i oz.). Should be aspirated four hours 
later. 

Klemperer' s Test Meal: — Milk, 500 c.c. (i pt.); 2 rolls 
(70 gm.). Give on empty stomach and aspirate two hours 
later. 

Boas {Non-lactic Jcid-containing) Test Meal. — One oz. 
(30 gm.) rolled oats boiled in i pt. (500 c.c.) water; salt q. s., 
or 2 shredded wheat biscuits with 300 c.c. (10 oz.) water. To 
use when testing for lactic acid the stomach should be washed 
out the night before. 

Salzer's Double Test Meal. — Beef, 40 gm. (ij oz.); scraped 
and broiled; milk, 250 c.c. (8 oz.); boiled rice, 50 gm. (if oz.); 
I soft-boiled egg. Four hours later give Ewald-Boas test meal 
and remove one hour afterward. 

GASTRIC MOTOR MEALS. 

Fo7i Luebe. — Soup, 400 c.c. (13 oz.); beef, 200 gm. (6| oz.); 
bread, 50 gm. (if oz.); water, 200 c.c. (6f oz.). If at the end 
of six hours gastric lavage fails to show a residue, the motor 
power of the stomach is normal. 

Boas. — If two hours after an Ewald-Boas test meal the 
stomach is empty by lavage, there is normal motor power. 

Hausmanns Stagnation Test Meal. — Four tablespoonfuls of 
boiled rice and a glass of water are given at 9 p.m. (a little 
sugar and milk can be taken on the rice). If at 9 a.m. next 
morning fasting, lavage fails to show macroscopic or micro- 
scopic rice residue, there is no stagnation. (A drop of Lugol's 
solution stains any starch granules blue so that they are easily 
seen.) 

Test Supper. — For supper, meat, bread, butter and water or 
two cups of tea. Lavage in the morning following should fail 
to show any residue in a normal stomach. 

Water Test for Acidity.^ — Carlson, Orr, Hanke, Brackman 
and Rehfuss all observed that the taking of water stimulated 
gastric secretion, producing an acidity that was about 100 in 
less than twenty minutes after stimulation. They found that 
in ten to twenty minutes 500 c.c. (10 oz.) of water would leave 
the stomach (.? Ed.) and also that after drinking 50 c.c. 
(if oz.) of water as much as 225 c.c. (7 oz.) of gastric juice 
could be obtained. 

Austin's meal directions are as follows, partially based on 
the foregoing: Previous evening the patient takes a meal of 
meat, potato, bread, butter, rice and raisins and presents him- 

1 Austin: Boston Med, and Surg. Jour., 1915, clxxii, 857. 



GASTRIC MOTOR MEALS' §41 

Self the next morning for examination, fasting. Then 350 c.c. 
(12 oz.) of water are given and removed by the stomach-tube 
in twenty minutes. Austin found the total acid values much 
lower than those already quoted, varying from 19 to 31. 

Intestinal Motor Meal { Schmidt- Strassburger),— With the 
meal two capsules, each containing 0.5 gm. (7i gr.) of charcoal 
are given to mark the meal, then the following: finely cut meat, 
80 gm. (2f oz.); mashed potato, 200 gm. (6| oz.); eggs (2); 
butter, 40 gm. (ij oz.); oatmeal gruel made with milk, 1500 
c.c. (3 pt.); clear soup, 250 c.c. (8 oz.; very dry toast or zwei- 
back, 100 gm. (3I oz.). In health it is said this should pass 
through the intestine in fifteen to twenty-five hours. In 
diarrhea due to colitis, in ten to fifteen hours. In enterocolitis 
with diarrhea, in three to five hours (Strauss). 

For further intestinal test diet see Schmidt, Intestinal Diet 
(p. 344)- 



CHAPTER XXI. 

DIET IN DISEASES OF THE INTESTINES. 

For the most part too little distinction is made between 
the various portions of the intestine involved in disease, 
roughl}^ dividing the cases into affections of the small or large 
intestine. Whether the particular case under discussion has 
constipation or diarrhea is certainly an important considera- 
tion, but more than that is needed, and besides the actual 
pathological condition of the intestine, one must consider the 
integrity of the accessory digestive glands, notably the liver 
and pancreas. So it is that one constantly sees cases of diar- 
rhea called chronic enteritis in which the intestine is perfectly 
normal, but the cause of the disturbance may be found to lie 
in the absence of gastric secretion — or in a pancreas which for 
some reason no longer produces its usual secretion. Here, 
too, we often see the most marked examples of pure functional 
disturbances due to lack of nervous stability, for the intestinal 
neuroses of all forms are comparatively common. 

ACUTE ENTERITIS. 

Enteritis, or inflammation of the small intestine, is of fre- 
quent occurrence and one has only to glance over the etiologi- 
cal factors to realize how many conditions there are that may 
give rise to it. Among these causes may be mentioned dietary 
indiscretions, unhygienic surroundings, frequent exposure to 
sudden atmospheric changes, irritants, as some acids, mer- 
cury, arsenic, cantharides, copper, tartar emetic, garlic, 
alcohol. Blood irritants, seen in uremic conditions; mechan- 
ical irritants; bacillary infections of the intestinal tract; 
parasites; the exanthemata; chronic constipation; intestinal 
obstruction; disturbances of circulation; drinking ice-water 
to excess,^ etc. 

The inflammation may affect any part of the small bowel, 
so that we may have a duodenitis (distinguishable from the 
other locations on account of the frequency of a complicating 
jaundice); jejunitis and ileitis. Aside from the duodenitis, of 
course it is impossible clinically to distinguish which part of 
the bowel is involved. 

^ Gant: Diarrhea Inflammation and Parasitic Intestinal Diseases, p. 176. 



ACUTE ENTERITIS 343 

Conheim} divides enteritis into: 

1. Mild enteritis without diarrhea, but with numerous symp- 
toms, such as meteorism, abdominal pains, flatulence and loss 
of strength. 

2. Moderately severe enteritis with much intestinal fermen- 
tation and frequent diarrhea. 

3. Severe cases with persistent diarrhea. 

The dietetic treatment of the acute cases resolves itself into 
a negative and positive phase. Under the former we are con- 
tent during the acute onset to withhold all food for twenty- 
four hours or possibly longer, giving only water and a good 
cathartic to relieve the bowels of any offending matter; for in 
spite of the diarrhea which is present in the moderate or severe 
cases, nature usually needs assistance in this. 

This is particularly true in the severe acute type, ordinarily 
known as cholera morbus. After the preliminary period of 
starvation one may begin feeding thin gruels, albumin water, 
rice, or toast, water and weak tea. Milk is best left out of 
the diet at the outset, for it is seldom properly digested while 
peristalsis is so active and even in the late stages it fails to 
agree as well as some of the carbohydrate or other protein 
foods. Some cases, however, do well on boiled milk, for the 
boiling causes it to respond to the gastric enzymes in a fine 
flocculent curd; in still others it can be given advantageously 
raw and over long periods. When the disease reaches the 
subacute stage in mild cases, one may feed most of the soft 
foods, such as eggs, soft meats, sweetbreads, stewed or boiled 
chicken, creamed fresh cod, halibut and whitefish. If there is 
not much flatulence one may give the fine cereals well cooked, 
farina, cream of wheat, rice, wheatina, malted breakfast food 
with a little butter and salt. These cereals are not good when 
there is a tendency to or actual excessive carbohydrate fer- 
mentation in the intestine, as shown by explosive acid stools 
and an active formation of CO2 in the fermentation tube. 
Later on soft-cooked or puree vegetables put through a 
colander are allowable, such as spinach, peas, potatoes, car-, 
rots and celery, but as a rule vegetables should be left out of 
the diet on account of their laxative eff'ect. Soft custards, 
blanc mange, farina or rice pudding and gelatin desserts are 
allowable in the mild or subacute cases. 

There are very definite foods which should not be eaten at 
any time in any type of this trouble, such as coarse or irritat- 
ing foods, those which ferment easily or putrify readily, and 
all the foods given must be soft and free from indigestible 

^ Forchheimer : Therapeutics, iii, 197. 



344 



DIET IN DISEASES OF THE INTESTINES 



particles. Not much sugar should be given. Wines, beer or 
champagne are not allowed with the exception that in the 
later stages a little diluted claret or sherry may be permitted. 

Among the vegetables under the ban are cauliflower, tur- 
nips, cabbage, radishes, onions, tomatoes, celery root, oyster 
plant and Brussels sprouts. No fruit may be taken, nor cake, 
rich jellies or other sweets. Rich cheese, high meat or game 
are also forbidden. 

In general the milder the case, the less strict need the diet 
be and vice versa. 

CHRONIC ENTERITIS. 

This may be chronic from the start or may be the remains of 
an acute attack, the etiology being the same as that of the 
acute cases, but acting more slowly, or it may be an accom- 
paniment of other diseases of the bowels as, e. g., carcinoma, 
intestinal obstruction, fecal impaction, etc.^ In the chronic 
forms of enteritis, it is particularly satisfactory to make a 
definite test of the patient's digestion as affecting the proteins, 
fats and carbohj^drates, after which it is possible to plan a 
rational diet suited to that individual's needs. 

This is arrived at most certainly by placing the patient on a 
Schmidt test diet, which is as follows: 

Schmidt Test Diet. — In the morning, 0.5 liter (16 oz.) milk, 
or, if milk does not agree, 0.5 liter (16 oz.) cocoa, prepared from 
20 gm. (I oz.) cocoa powder, 10 gm. (J oz.); sugar, 400 c.c. 
(13 oz.); water and 100 c.c. (3I oz.) milk. 

In the forenoon, 0.5 liter (16 oz.) oatmeal gruel, made from 
40 gm. {i\ oz.) oatmeal, 10 gm. (J oz.) butter, 200 c.c. 
(6J oz.) milk, 300 c.c. (10 oz.) water; i egg strained. 

At noon, 125 gm. (4 oz.) chopped beef (raw weight), broiled 
rare with 20 gm. (| oz.) of butter, so that the interior will still 
remain raw. To this add 250 gm. (8 oz.) potato broth, made 
of 190 gm. (6-3- oz.) mashed potatoes, 100 c.c. (3I oz.) milk, 
and 10 gm. (J oz.) butter. 

In the afternoon as in the morning. 

In the evening as in the forenoon. 



This diet cons 



Milk . . 
Zwieback . 
Eggs . . 
Butter 
Beef . . 
Potatoes . 
Oatmeal (gruel) 



sts of: 



1.5 liters (15 qt-) 

100. o gm. (3^ oz.) 

2.0 

50.0 gm. (if " ) 

125.0 gm. (4 " ) 

190.0 gm. {6\ " ) 

80.0 gm. (2I " ) 



This contains protein, 102 gm. (3I oz.); fat, III gm. (4 oz.); 
carbohydrates, 191 gm. (6\ oz.); calories, 2234. 

1 Stengel, in Osier's Mod. Med. 1914, 2d ed. 



CHRONIC ENTERITIS- 



345 



In order to carry this diet out most satisfactorily it is best 
to give it for a couple of days and then give two capsules each 
containing lo grains of charcoal. This is given again at the 
end of the test period of two, three or four days as may have 
been decided and the stools and urine saved accurately for 
the period which is marked at its beginning and end by the 
charcoal. 

The result of the examination of the feces will show whether 
the stools contain undigested food, meat fibers, connective tissue, 
free starch, fat drops, fatty acid needles, soaps or parasites. 
At the same time the pancreatic ferments may be tested for 
and the presence of carbohydrate and protein fermentation 
disclosed if it is present. Also the prevailing bacterial growth 
whether Gram-negative (normal) or Gram-positive. 

It will be found that a good many patients, particularly 
women and especially so if both their stomach and intestinal 
digestion are poor, cannot take the full Schmidt diet, the 
quantity is too great. In such instances the test diet as modi- 
fied by the author will be found very serviceable as containing 
the proper proportions of food elements and of sufficient caloric 
value. 

Modified Schmidt Diet. 



Protein. 


Fat. 


Carbohydrate. 


Calories 


Oatmeal . . 165 gm. (5^ oz.) 4.4 


0.8 


18.2 


TOO 


Rice . . . 90 " (3 " ) 2.4 


0.8 


21.0 


TOO 


Milk . . . 1500 c.c. (50 " ) 49.5 


60.0 


67-5 


1080 


Butter . . 40 gm. (i^ " ) 0.6 


340 




318 


Bread . . 120 gm. (4 " ) 13. i 


2 4 


80.0 


400 


Chopped meat 65 gm. (2 " ) 17. i 


4-7 




100 



87.1 gm.. 102. 7gm. 186.7 gm, 2088 

Breakfast. Dinner. Supper. 

Oatmeal, 165 gm. (5^ oz.) Meat, 65gm. (i oz.) Rice, 90gm. (3 oz.) 
Milk, 250 c.c. (3 " ) Bread, 40 " (i^ " ) Bread, 40 " (li " ) 
Bread, 40gm. (i^ " ) Milk, 250 c.c. (8 ") Butter, 15 " (| ") 
Butter, 15 " (^ " ) Butter, logm. (^ " ) Milk, 250 c.c. (8 " ) 
At 10, 3, and 9 o'clock, 250 c.c. milk. 

Having determined the digestive capacity of the pancreatic 
or intestinal enzymes by the use of the Schmidt diet, the task 
still remains of constructing a suitable diet for these patients. 
Chronic enteritis is not a condition that shows rapid improve- 
ment and weeks and months must often elapse before any- 
thing like satisfactory progress can be expected. On this 
account patients must be warned and told to expect slow 
changes, as otherwise they are quite sure to become discour- 
aged and blame their medical attendant for failure to improve 
rapidly. When the stools show undigested food, whether diar- 
rhea is present or not, the diet is not what it should be and 



346 DIET IN DISEASES OF THE INTESTINES 

the first constant aim must be to get a diet that can be digested, 
showing a normally smooth stool, even though its consistence 
may be too soft or fluid. This, of course, can only be done 
by painstaking changes with constant stool inspection to 
check up the condition of digestion. 

It is usually a good plan in starting the dietary treatment 
of these cases to begin with a liquid or semiliquid diet. Just 
which combination of foods will fit the individual case can 
only be determined by trial, but an ordinarily successful plan 
is to feed them every two hours with gruel, malted milk, cocoa 
and soft egg. Some cases digest boiled milk well and it is 
often deserving of a trial. If it is not digested as shown by 
curds and more active diarrhea then it should be omitted, 
even in the cocoa which should then be made with water. 
After a few days of this rigid diet, one may begin to add one 
extra at a time, preferably with every other feeding, i. e., 
every four hours. These extras may be in the form of fine 
cereal, farina, cream of wheat, wheatena, eaten with a little 
butter and salt or with a little malted milk over them. Then 
dry toast with or without butter is added. After which one 
may keep on gradually increasing the foods to boiled rice, 
macaroni, dry cheese, cream cheese, toasted crackers. By 
this time, it is well to lengthen the feeding interval to three or 
four hours. The character of the diet can be changed as 
rapidly as improvement in symptoms comes, adding next finely 
minced chicken and sweetbreads, lamb, boiled fresh white- 
meated fish. Desserts made of gelatin, egg or farinaceous 
puddings, later cream desserts, all made with the minimum 
amount of sugar. All vegetables should be left out of the diet 
for a long time, but when taken they should be thoroughly 
cooked, soft, and put through a colander, or in the form of a 
puree. Fruits should be added last and then only well-cooked, 
soft fruits, such as baked apple (without the skin), apple sauce, 
etc. Of course, fruit should not be given until the stools are 
of normal consistence and well digested and it will be probably 
weeks or months after starting treatment before it can be given. 

ACUTE COLITIS OR ACUTE DYSENTERY. 

Acute dysentery is caused by a variety of factors, bacillary, 
protozoon and constitutional, and results in an acuteh^ 
inflamed colon mucous membrane which may or may not go 
on to ulceration, depending on the form and severity of the 
exciting cause. It is often found as a part of an infection 
involving the small intestine as an enterocolitis, or it occurs 
alone. 



CHRONIC COLITIS 347 

When it occurs as part of an infection higher up, the dietary 
treatment is in accordance with the needs of the small intes- 
tine, when it occurs alone it is often very sudden and severe 
in its onset and requires great care in treatment. After a 
complete emptying of the bowel by catharsis, it is a good plan 
to withhold food for twenty-four hours in order to quiet the 
peristalsis, using opium or other antiperistaltic agent. When 
feedings are begun they should be liquid and at first largely 
protein, as whey, albumin water and clear soups, then gruel 
made of oatmeal, farina or wheat cereals or koumyss; sweet 
milk should not be given, as it tends to increase the diarrhea, 
although this is less marked if the milk is boiled. Later, 
scraped m.eat, dry toast, well-cooked fine cereals, soft-boiled 
or poached eggs, macaroni, well-boiled rice, weak tea or a little 
dilute whisky or claret form the bulk of the diet. When the 
acute symptoms subside the patients are either well or the 
disease goes on into the chronic stage. In the acute stage 
fruit and vegetables are to be avoided. 

CHRONIC COLITIS. 

Whatever the origin of the colitis or whatever pathological 
form it takes, there are certain dietary conditions which must 
be taken into consideration and met in all cases. 

1. That the diet must be made up of easily digestible foods. 

2. That the foods must not be stimulating to peristalsis. 

3. That all food must be finely subdivided, soft and with as 
little digestive residue as possible. 

4. The quantity of food must be sufficient for complete 
nutrition in nitrogen and calorie content. 

As to the first point the foods particularly suitable are: 
clear, cream or puree soups, white-meated fish; (other richer 
forms later if they agree with gastric digestion); soft part of 
oysters, beef, mutton, chicken, sweetbreads, eggs, fine cereals, 
farina, cream of wheat, malted breakfast food, wheatena, tea, 
coffee, cocoa made with water, butter, toast, stale bread, roll, 
puree of vegetables such as potato, lima beans, peas, spinach, 
stewed celery, baked Hubbard squash. (In many cases no green 
vegetables can be taken at all on account of increased peristalsis.) 
Farinaceous puddings, gelatin desserts, egg desserts. (For 
food stimulating to peristalsis see section on Diarrhea.) In 
general it may be said that fruits, coarse vegetables (in some 
cases any vegetables), very sweet foods, much fat food, are 
all stimulating and must be avoided. Milk is also in this class 
for most patients, although occasionally a patient can take 
it boiled or diluted with gruels. Sometimes koumyss will be 



348 DIET IN DISEASES OF THE INTESTINES 

better digested than plain milk. White wine, beer, ale and 
champagne are contra-indicated. 

That patients should receive sufficient food for nutritional 
uses is self-evident, but it is not by any means easy to nourish 
many of these patients completely, as there is often much 
anorexia, and if pain is also present, it is still more difficult to 
feed them. 

In the long-standing cases, particularly those due to ulcer- 
ative colitis, malnutrition is more or less the rule and some 
patients lose as much as half their body weight, it being impos- 
sible to get them to take a sufficient supply, and the ingenuity 
of the physician is put to a severe test. In these long-standing 
and severe cases the use of artificial food materials is often 
useful (see Artificial Foods) to fortify soups and gruels. 

MEMBRANOUS COLITIS, MUCOUS COLIC OR CHRONIC 
MUCOUS COLITIS. 

It was formerly thought that these cases were in the last 
analysis of a neurotic origin, occurring only in nervous per- 
sons; and while many of the patients were nervous it was also 
observed that the disease occurred in those who were not at 
all so. Nothnagle was largely responsible for this general 
belief, but time has proven it untenable when applied to the 
cases as a class. The characteristic feature of the disease is 
the passage of mucous strips, bits, ribbons or even entire casts 
of parts of the colon and accompanied by more or less abdom- 
inal pain. There are two groups^ ordinarily distinguished. 

I. Those with pain along the colon and a tendency to 
diarrhea, i. e., chronic mucous colitis. 

2. Those occurring in nervous persons who have chronic 
constipation and attacks of "membranous colitis" or "mucous 
coHc." 

The diet in the first group is so constructed as to spare the 
bowel as much irritation as possible and consists largely of 
albuminous foods together with farinaceous gruels, all coarse 
foods are excluded as well as vegetables and fruits, the rest 
of the feedings are as already described in the section on 
Enteritis or Chronic Colitis. In the second group there is 
reall}^ a catarrh of the bowel and in addition, chronic consti- 
pation. Von Noorden fastened upon the chronic constipation 
as the essential feature of the disease and by combating this 
was able to clear up the mucous stools. In order to accomplish 
this he prescribed a diet with much cellulose, indigestible resi- 

1 Forchhcimcr, vol. iii. 



ULCERATION OF THE INTESTINES 349 

due in skins and seeds, coarse black or rye bread, crude vege- 
tables, raw or cooked, but the rougher the better, cabbage, 
tomatoes, turnips, carrots, celery, cauliflower, Brussels sprouts, 
corn, etc., also large amounts of fats in the form of cream, 
butter, fat meats and oils. Cider and buttermilk are both 
good for this purpose. 

The following diet devised by Butman is recommended 
and is also good for chronic constipation generally. 
On rising, a glass of cold water. 

Breakfast: Oatmeal, whole wheat or graham bread (or 
bran bread), butter, coffee, raw or cooked fruit. 
Marmalade (honey). 
Midmorning: A glass of buttermilk or cider, or water, 

dried fruit, figs, dates or prunes. 
Luncheon: A small amount of meat, fish or other sea-food, 
two or more green vegetables, coarse bread, butter. 
Fruit. 
Midafternoon: A glass of buttermilk or cider, etc. 
Dinner: Fruit, meat or fish, two or more green vegetables, 
coarse bread, butter (bran bread or biscuits), salad, 
dessert, preferably a fruit dessert. 
Bedtime: Same as midmorning. 
Or the diet recommended under Chronic Constipation. 

ULCERATION OF THE SMALL OR LARGE INTESTINE. 

Ulceration of the small or large bowel occurs in a variety of 
conditions, e. g., simple ulceration as in duodenal ulcer or as 
the result of typhoid fever, tuberculosis or other bacterial or 
protozoan diseases. 

In simple or typhoid ulceration the diet has already been 
described under these headings. In tuberculous ulceration 
and that due to other bacteria, as in chronic dysentery or 
amebic dysentery, the dietary regulations are practically alike. 
The diet should be free of irritating foods^ seeds, skins, raw 
vegetables or those with a rough residue, as corn, bran, etc. 
Everything should be exceedingly soft and of moderate bulk. 
When diarrhea is present one must be governed in the selec- 
tion of food by a knowledge of what foods are naturally laxa- 
tive and avoid them, using on the contrary the classes of 
foods which have been described under Enteritis and Diarrheal 
Diseases in general. 

Laxative foods include fruit, vegetables, indigestible fats, 
sugars, game, "high" meat, malt liquors, rough substances, 
such as bran. 



350 DIET IN DISEASES OF THE INTESTINES 



INTESTINAL HEMORRHAGE. 

The diet in intestinal hemorrhage, if at all severe, should be 
regulated much as has already been described under Hemor- 
rhage in Typhoid. All food by mouth should be stopped at 
once. If the hemorrhage is from a point high up in the intes- 
tine, as that from duodenal ulceration, not even water should 
be given for from forty-eight to seventy-two hours. (See 
Duodenal Ulcer, p. 309.) If the patient is desiccated it will 
be necessary to give warm saHne by the rectal route within six 
hours of the hemorrhage, either as a continuous Murphy 
drip, or in repeated amounts of 4 to 6 ounces every two, 
three or four hours. If the hemorrhage is from lower down, as 
from the ilium in typhoid, water may be begun within six 
hours, and within twelve to twenty-four hours one may again 
begin mouth feedings with broth, albumin water, malted milk 
or diluted citrated milk (i grain of sodium citrate to the 
ounce). After another six to twelve hours the feedings may 
be gradually and steadily increased again until full fluids are 
being taken. It is not necessary to interdict water in these 
cases and this may be given in small amounts, frequently 
repeated two or three hours after the hemorrhage. Large or 
very hot enemata of water should not be given on account of 
their tendency to dilate the abdominal vessels, which of course, 
increases the danger of hemorrhage. When the hemorrhage 
is from the colon, it is scarcely ever severe enough to cause 
anxiety and only in exceptionally large hemorrhages need one 
hesitate to continue giving fluids by mouth. Of course, under 
this circumstance no fluid should be given by rectum. 



DIARRHEA. 

As diarrhea is merely a symptom, a classification of its 
etiology would include a discussion of every condition which 
may give rise to this symptom, the treatment being often 
quite as various as the etiology. 

The Causes of Dirrhea. — In general the causes of diarrhea 
may be enumerated as follows: 

Gastrogenic- — When achylia gastrica is present this in some 
way predisposes to diarrhea, probably the lack of acid secre- 
tion fails to call out the pancreatic enzymes sufiiciently to 
properly digest the food, and diarrhea results. 

Toxic. — In cases of chronic Bright's, diarrhea is often present 
and represents the attempt of nature to eliminate water, 



DIARRHEA 351 

chlorides, toxic material and probably nitrogen by way of the 
intestinal mucosa, being therefore a vicarious diarrhea. Other 
varieties of toxic origin are seen in the acute bacterial intes- 
tinal diseases, typhoid, cholera and cholera morbus; pto- 
maine toxemia including all forms of food poisoning, which 
are almost invariably accompanied by diarrhea. The toxic 
effect of the inorganic salts must also be included, principally 
arsenic, mercury and antimony, and to the milder toxic infec- 
tions, such as intestinal catarrh, acute and chronic. 

Irritative Diarrhea, which may be toxic or merely mechan- 
ical, as the eating of quantities of indigestible food such as 
corn, fruit in excess, etc., excess of gastric free HCl. 

Drug Diarrhea, due to ingestion of laxative drugs which if 
taken in excessive amount or over long periods, often continue 
the diarrhea after the complete elimination of the drug which 
is then probably due to a catarrhal inflammation. Ulcerative 
conditions of the gastro-intestinal tract — peptic, tuberculous 
and simple ulcer or the numerous forms of diarrhea due to a 
diseased colon. 

Nervous Diarrhea. — Many people have this difl&culty in the 
face of some unusual excitement, soldiers, musicians, and in 
hysteria and are all due to vasomotor dilatation in an unstable 
nervous system, causing the so-called "sweating" of the intes- 
tine. Under this heading the diarrhea of hyperthyroidism may 
belong, although this is quite as likely to be due to the general 
toxemia seen in these cases. Reflex diarrhea is also of nervous 
origin. 

Hahit Diarrhea. — Some persons normally have several more 
or less watery stools a day or they may have a morning diar- 
rhea, often due to catarrh, however. 

Diarrhea due to Food Idiosyncrasy. — In these cases some 
one article of food may habitually excite a diarrhea quite 
apart from any known toxic or mechanical effect, although it 
is probably of toxic origin in the last analysis. 

Diarrhea of Pancreatic Origin. — Where the ferments are 
deficient, as the well-known fatty diarrhea. 

Diarrhea occurring as secondary to periods of fecal impaction 
with a. tunneling of the fecal mass, or alternating with severe 
constipation. 

With all these forms of diarrhea the etiology gives the 
clue to the dietetic treatment and an accurate diagnosis is 
always essential to a satisfactory and intelligent ordering of 
foods. 

It is unfortunately not possible to find in every case the 
actual cause, so that the clinician is not infrequently called 



352 DIET IN DISEASES OF THE INTESTINES 

upon to prescribe a diet for diarrhea in which the etiology is 
obscure and eludes the most painstaking investigation. The 
underlying principles are much the same in ordering diets for 
almost all the forms of diarrhea and may be described as 
follows : 

Dietary Regulations. — The diet should be non-irritating, 
easily digested, not a stimulant of peristalsis, free from taint 
of putrefaction, finely comminuted and should include as 
many articles of food that are naturally astringent as possible, 
and not apt to ferment. 

In acute diarrhea from any cause a period of starvation 
following an intestinal purge is the best dietetic routine, 
allowing fresh but not cold water in abundance. When the 
appetite begins to demand food, clear broth, beef tea, cereal 
gruels, dry toast and tea are best for a day or two, gradually 
extending the list from foods which are allowed in chronic 
diarrhea. 

Foods to Avoid in Chronic Diarrhea. — Very fatty foods, except 
a moderate amount of butter. Raw milk and cream. Green 
vegetables of all sorts. Boiled potato. Corn is especially 
irritant. Fruit in all forms is forbidden, whether stewed or 
fresh. Salads, nuts, pickles, condiments. Salt meat or salt 
fish. Smoked meats or fish. Goose, duck, pork as too fat. 
Sweets, cake, pie, candy, and preserves. Cream or milk 
desserts. Sweet wine, beer and ale. 

Foods Recommended in Diarrhea. — Clear soups, white-meated 
fish (not fatty), e, g., cod, halibut, bass. Chicken, mutton or 
lamb, scraped beef, soft part of oysters. Guinea hen. Soft 
eggs. Rice, macaroni, noodles. Baked potato may agree. 
Cereals except oatmeal or pettijohn. Stale bread or dry toast, 
crust of roll. Toasted crackers. Cream, Edam, Canadian 
Cheese. Farinaceous puddings made with little sugar, pref- 
erably baked. Calf's foot or wine jelly. Tea, clear coffee 
(in some cases this is laxative), water, claret. Burgundy. A 
little diluted whisky or brandy. In some instances malted 
milk is well tolerated, while in others it is laxative. In a few 
cases it is possible to give boiled milk, but for the most part 
milk in any form is very badly tolerated causing an increase 
in the diarrhea with the passage of undigested curds. 

Foods Allowed in Certain Cases. — The use of malted milk or 
cereal is useful unless it proves laxative. Crisp bacon, turkey, 
koumyss, zoolak, buttermilk. Thoroughl}^ stewed celery, 
baked Hubbard squash, creamed spinach, tender boiled peas 
or lima beans mashed through a colander, removing the 
skins. 



INTESTINAL NEUROSES 353 

Chronic Diarrhea — Cohnheini s Diet List {American Modifi- 
cation) . 

7.00 A.M. Mineral water, 75 to 150 c.c. (2 J to 5 o'z.), taken 
hot on rising. The choice of water will depend 
on gastric secretions, with hypoacidity or 
achylia, sodium chloride and alkaline waters 
are best. At home 10 grains of salt and 10 of 
bicarbonate of soda may be added to the 
allowance of hot water. 
7.30 A.M. Philip's digestible cocoa (2 teaspoonfuls to a 
cup) made with water. Toasted white bread 
and butter. 
10.30 A.M. Fine cereal, cream of wheat or farina or malted 
breakfast food, one soft-boiled egg or scraped 
meat or lamb chop cut fine. 
1. 00 P.M. Broth with macaroni, vermicelli or noodles. In 
mild cases vegetable purees. One glass of 
claret. 
4.00 P.M. Same as 7.30 a.m. 
6.00 P.M. Mineral water as in early morning. 
7.00 to 8.00 P.M. Tea with claret. Toast, butter and a 

little cold chicken. 
9.00 to 10.00 P.M. A cup of hot peppermint tea or chamo- 
mile tea. If the case is mild and the 
stools soft rather than liquid, some 
soft carrots, fillet of sole or baked fish 
is allowed. 
Absolutely Forbidden Articles. — Cold drinks, all rough or 
coarse vegetables, such as cabbage, potatoes, cheese, sweets, 
coflFee. All legumes unless served in soups; goose, duck, fat 
fish as salmon, mackerel, blue fish, meat fats, gravies, raw 
fruits. 

INTESTINAL NEUROSES. 

These follow much the same classification as the gastric 
neuroses, except that intestinal pain of a purely nervous origin 
is rare and as a diagnosis should only be made after a careful 
process of exclusion and even then with reservation. The diet 
in these intestinal cases is much on the same lines as that 
recommended for definite intestinal pathological states which 
symptomatically they often so closely simulate, e. g.y in ner- 
vous constipation, besides the general tonic treatment of the 
nervous system, the diet should be that recommended for 
chronic constipation with a large percentage of roughage in 
the form of fruits, vegetables, and bran. With the opposite 
2.3 



354 DIET IN DISEASES OF THE INTESTINES 

condition, namely, that of a nervous diarrhea, a diet such as 
that advised for chronic diarrhea is advisable (p. 350). On 
the other hand, one sees not a few cases of a type of nervous 
diarrhea which presents a characteristic picture of an under- 
nourished, anemic, worried, irritable individual, man or 
woman, who gives a history of a diarrhea of months' or years' 
standing, from whom the history is obtained that little by 
little they have curtailed their diet with the idea that first 
one thing, then another disagrees and causes the diarrhea until 
they are living on perhaps only three or four articles of food 
with an entirely inadequate number of calories. The stools 
are more or less numerous, liquid or semiliquid which on 
analysis show no other abnormal characteristic than possibly 
some little mucus and a few leukocytes. If one is sure of one's 
ground in dealing with these people and can reassure them 
and gain their confidence it is usually possible to begin feed- 
ing them liberally at once and a good meal of finely cut tender- 
loin, baked potato or rice, green peas and a simple dessert 
will do more to restore confidence than anything else. The 
character of the stool may not change at once, but will usually 
return to normal within a few days and the diet can then be 
rapidly increased to a general mixed one with full confidence 
that it will be satisfactorily digested. 

The anemia should also be treated and a general course of 
sensible hygiene insisted upon. 

CHRONIC CONSTIPATION. 

If an aboriginal text-book on medicine should be found, it 
would probably be noted that there was no chapter on chronic 
constipation, this being a disease of modern life, a product of 
inactivity and a non-stimulating diet. The causes of consti- 
pation are numerous, some predisposing, some direct. Faulty 
habits of eating are most largely responsible and a diet with 
little residue from cellulose will be very apt to result in consti- 
pation. Any condition which tends to the weakening of the 
voluntary or involuntary muscles will also tend to produce or 
exaggerate a tendency to constipation, such as illnesses of all 
kinds, lazy habits of exercise and irregularity in attempted 
evacuation, all have much to do with it. Chronic constitu- 
tional diseases producing a congestion of the abdominal organs 
will result in constipation. 

Varieties of Constipation. — The cases divide themselves into: 

1. Functional, either (a) atonic or (b) spastic. 

2. Organic from mechanical obstruction of the lumen of the 
gut, from within or without. 

Of all forms, the atonic comprises most of the cases, possibly 



CHRONIC CONSTIPATION 355 

90 per cent., and is due to a lazy or inactive bowel. The 
spastic variety is the direct opposite of this, in that it occur- 
as a product of overstimulation of the intestinal nerve ends 
ings, giving rise to spastic contraction of the bowel and pain. 
The form of constipation due to mechanical obstruction speaks 
for itself and is of only minor interest from a dietetic point 
of view. 

In the atonic constipation, every means possible must be 
used to awaken the bowel by mechanical stimulation, as by 
massage, exercise of the abdominal muscles and general body 
exercise, calisthenics or out-of-door work. 

In the selection of a diet the two important facts to be 
remembered are that the food must be as coarse and rough 
as possible, and that all sorts of fats are very valuable in pro- 
moting ease of evacuation. In many or most of the patients 
suffering from chronic constipation, the stools are of small 
bulk and the more severe the constipation the smaller the 
bulk of the stool, as the sluggishness gives an extra amount of 
time for the further and more complete disintegration and 
absorption of the foods. In other words, digestion and absorp- 
tion are often at their highest in chronic constipation, and if 
there was not sometimes absorption of other things besides 
the food, such as various digestive by-products and the prod- 
ucts of bacterial putrefaction, chronic constipation would not 
be so undesirable. As it is, the condition is not ordinarily a 
favorable one for health or well-being; although there are 
many cases who do not have a movement of the bowels more 
often than once or twice a week, yet who seem to keep in 
perfect health and vigor. 

Taking food into the stomach at once excites not only peris- 
talsis of the stomach but also of the bowels and particularly 
of the caput coli, so that there is good physiological reason for 
the desire to defecate shortly after a meal and particularly 
after breakfast, which should be the preferable time for evac- 
uation. Peristalsis is especially "stimulated by indigestible 
meat residue, vegetable fiber, cellulose, sugar and organic 
acids. Peptones stimulate it feebly, oils more strongly and 
gases in especially CH4 and SH2 even more powerfully."^ 

Atonic Constipation. — Since in this condition the bowel 
needs stimulation one must give a coarse diet with a large 
residue much as has been recommended for *' membranous 
colitis," following von Noorden's suggestion and copying arti- 
ficially, so far as one can, the diet that is eaten by semicivil- 
ized or wholly barbarous people. This should include much 
uncooked food in the form of vegetables, nuts and fruits of all 

^Tibbies: Food in Health and Disease, p. 349. 



356 DIET IN DISEASES OF THE INTESTINES 

sorts. The bread eaten should be whole wheat, rye, gluten 
or bran bread, to which nuts and raisins can be added. 

Vegetables. — All vegetables are good, raw celery and cold- 
slaw or cooked cauliflower, turnips, asparagus, carrots, par- 
snips, salsify or oyster plant are especially good. Jerusalem 
artichokes, raw or cooked celery, squash, either the summer 
variety or Hubbard squash, the latter preferably baked; all 
beans and all vegetable and fruit salads. A good rule for these 
patients is to help themselves to a double portion of vegetables. 

Meat. — Fat meats are best, unless it is important to keep 
down the weight. 

Eggs and fish are also allowed. 

Cheese, except cream cheese, is forbidden. 

Fruits, especially those with much residue, pears, melons, 
apple (a raw apple at bedtime often being very serviceable). 
Oranges and grapefruit, if the section divisions are also eaten, 
particularly in oranges. All berries except blackberries, which 
are rather constipating. Dried fruit of all sorts, figs, pulled 
or stewed, dates and raisins and all nuts. 

Desserts. — Fruit desserts or puddings, blanc mange, made 
with prunes, figs, raisins or fresh fruits. Other desserts are 
allowed, but are less stimulating. 

Salad. — All kinds. The coarser, the better. Those made of 
fruit and vegetables are particularly good, as apples and 
celery, alligator pear or any other fruit salad with lettuce. 

Fats. — Fats of all sorts, animal, vegetable and mineral are 
useful. The mineral oils introduced by Lane for intestinal 
stasis are often very beneficial. 

Each case of atonic constipation must be considered indi- 
vidually in prescribing a diet, as for example it would be 
actually wrong to order a diet with high fats for a person 
already overweight, or a diet principally vegetable and fruit 
for a person suffering from inanition. 

Chronic Constipation. — ^The following diet will be found 
generally useful, having due regard for the foregoing factors. 

On rising drink a glass of water, one-third to one-half grape 
juice or two glasses of plain water. 

Breakfast: Stewed fruit or fresh fruit. Oatmeal or petti- 
john breakfast food (25 per cent, bran), with cream 
and sugar, white or brown; or cornmeal mush with 
molasses, golden drip or maple sugar; eggs or bacon, 
whole wheat bread or bran bread or Grant's health 
crackers (bran) with fresh butter, if it is obtainable, 
(one eats more butter when it is fresh than when 
salted), or cooked bran may be mixed with the morn- 
ing dish of cereal, 



CHRONIC CONSTIPATION 357 

Midmorning: Drink a glass of water or eat some dried 
fruit, figs, dates or Bordeaux prunes, or fresh fruit 
in season. 
Luncheon or Supper: Small piece of meat or fish, two green 
vegetables from the list, whole wheat bread and fresh 
butter, bran bread or crackers. Fruit fresh or stewed. 
Prune or fig pudding, or salad with oil dressing. 
Dinner: Grapefruit, vegetable soup. Entree of fish or 
egg with caper sauce or plain. Small piece of fowl or 
red meat with fat. Two or more green vegetables from 
list, taken in double quantity, and cooked with but- 
ter or oil, unless it is necessary to keep the weight 
down. Salad of celery and fruit or lettuce and other 
vegetable with ship biscuit or bran cracker. Cold- 
slaw. OHves, radishes. Dessert — a fruit pudding, 
fresh fruit, stewed fruit, figs, nuts, raisins. 
Bedtime: Two figs, prunes or several dates. 
Of course one is not supposed to eat all the articles mentioned 
at one meal, but a choice made for each, varying it as to fats 
or vegetables, as necessity requires. 

Drinks. — Coffee, buttermilk^ cider, water, Vichy, grape 
juice, raspberry vinegar or some sweet wine, if one must have 
alcohol. 

The use of agar-agar preparations is sometimes recom- 
mended in these cases to give bulk to the feces owing to their 
power of taking up water. But much the same result can be 
obtained by the use of good amounts of vegetables and fruit. 
Spastic Constipation. — In this form of constipation it is 
necessary to furnish considerable bulk to the feces, but keep- 
ing all the foods soft and non-irritating, also to include a large 
percentage of fats and oils, making rather an especial point of 
this latter feature. It is here that the mineral oils may have 
their best effect and should be tried freely and thoroughly 
and as well, the injecting of 2 to 4 ounces of some bland oil 
into the rectum at bedtime. For this purpose one may use 
olive, cottonseed, peanut or sweet oil. Larger quantities are 
often recommended, but serve no more useful purpose than 
the small amount. In this diet the fruits should be freely 
used, but not those with seeds or skins; and raw, rough or 
uncooked vegetables must be left out of the diet. 

Potatoes, spaghetti and all cereal foods are good, except 
oatmeal or bran preparations and, of course, fish, eggs and a 
moderate amount of meat, free of connective tissue, are all 
allowable. 

If one will keep in mind the facts already stated, that the 
diet must contain a greatly increased bulk of soft vegetables 



358 DIET IN DISEASES OF THE INTESTINES 

and fruit and as large an amount of oils and fats as one can 
digest readily, the diet may be easily constructed. It is 
often better to take all the vegetables as a puree or after 
being passed through a colander. 

Obstructive Constipation.— The texture of the diet in this 
condition will depend largely upon the degree of obstruction; 
if slight, it will be only necessary to exclude all coarse food 
from the diet which will leave us much the same diet as has 
been recommended for spastic constipation. When the 
obstruction is more marked or severe, it will be necessary to 
confine the foods to those which leave the stomach largely in 
fluid or semifluid form, such as malted milk, citrated milk 
(i grain of sodium citrate to the ounce of milk), cream and 
puree soups, cream, meat cut very fine or scraped. Soft 
eggs. Mashed potato, oils, butter, fine cereal gruels, ice-cream 
and syrups. Of course when an obstruction reaches this point 
it becomes a surgical condition and should be so treated. The 
only cases of severe obstruction in which it is necessary to 
consider the diet for any but a few days, are those cases, 
which, for one reason or another are inoperable. 

The Use of Mineral Oil in Chronic Constipation. — This oil 
comes in various grades, heavy and light, made here and 
abroad, especially in Russia, hence the common name ''Rus- 
sian mineral oil." Many cases of chronic constipation are 
greatly helped by varying doses, from a tablespoonful morn- 
ing and night to double that dosage or more. Still others find 
that a tablespoonful at bedtime is amply sufficient, in short, 
each patient has to find the individual dose suited to the needs 
of their case. Many patients cannot take this oil at all, for 
although it is not absorbed, the entire amount ingested being 
recoverable in the feces, it not infrequently interferes with 
the normal digestive processes giving rise especially to intes- 
tinal indigestion, characterized by the symptoms of a mild 
enteritis accompanied by loss of appetite. Whether this acts 
partly on account of the depressing efl'ect of oils on gastric 
secretion or possibly on account of the same effect on the 
intestinal enzymes or again by mechanically preventing the 
digestive juices from attacking the foods is not definitely 
known. The essential thing, however, to remember is that it 
does not agree with all patients by any means and its effect 
on digestion must be watched. After considerable investiga- 
tion in regard to the different mineral oils and the diflerent 
methods of giving it, Bastedo^ came to the following conclu- 
sions, which are borne out by clinical experience. 

1 Jour. Am. Med. Assn., 1914, Ixiv, 808. 



INTESTINAL ATONY 359 

Dosage. — Half an ounce to three ounces a day. In the same 
patient, the same amount of each of the oils was required, i. e., 
heavy and light oil. 

Frequency of Dose. — The same amount daily seemed as effi- 
cient when given in one dose as when given in divided doses 
two or three times a day. 

Number of Stools. — ^To produce one or two copious stools a 
day the dose required varied considerably, but there was no 
difference noted on account of difference in the specific gravity 
or character of the oils. 

So far as therapeutic results are concerned the differences 
in the action of the three varieties of liquid petroleum, namely, 
light Russian liquid petrolatum, heavy Russian liquid petrola- 
tum and American liquid petrolatum, are too slight to be of 
importance. 

Character of Stools. — The stools were soft, usually formed, 
sometimes mushy, obviously greasy. They had a peculiar 
odor described as sour. Their consistency varied with the 
dose, but was the same for the different kinds of oil. 

Admixture of Oil with Other Ingredients of Stools. — Generally 
well mixed, but from time to time a patient would have a 
stool of free oil. This occurred with all varieties of oil. (It 
necessitated reduction of the dose, and if then the bowels were 
not active enough, the administration in addition of cascara, 
aloin, etc.) 

The increase in the quantity of oil used in America has 
stimulated production on this side of the water until now all 
grades of mineral oil may be had of native manufacture which 
are in every way as good as the imported brands. 

INTESTINAL ATONY. 

This condition affects chiefly the muscular coat of the large 
bowel and results in constipation, in fact a large majority of 
cases of chronic constipation are the result of an atonic colon. 

The diet to combat intestinal atony should be much the 
same as that recommended for chronic constipation and con- 
tains as large a percentage of cellulose and fats as possible. 
Suitable foods are: the breads which should be those made 
with whole wheat flour, rye flour or bran; vegetables; the best 
varieties of which are those having the largest residue, such 
as the cabbage family, spinach, string beans or dried beans, 
peas, parsnips, sweet potatoes, beet tops, etc.; the rough 
cereals as oatmeal (Irish) or pettijohn (which is 25 per cent, 
bran) or Kellogg's cooked bran, which can be eaten alone or 
mixed with other cereals. All fruits, fresh, stewed or dried are 



360 DIET IN DISEASES OF THE INTESTINES 

useful and should be taken in some form at least three times a 
day. Molasses, honey, marmalade and maple syrup are all 
stimulating to the intestine. The best fats are cream, olive 
oil, butter and fat meats — as bacon. Protein foods may be 
unrestricted in kind but should be somewhat limited quanti- 
tatively, for when taken in large amounts they tend to spoil 
the appetite for the more bulky and necessary vegetables and 
fruits. 

As additional measures, massage of the colon and elec- 
tricity (given with one electrode in the rectum) assist in wak- 
ing up a sluggish bowel. 

APPENDICITIS. 

Acute Appendicitis. — Acute appendicitis whether catarrhal, 
suppurative, gangrenous or perforative, is essentially a sur- 
gical disease and should be so considered from the onset. 
There are certain conditions, however, under which acute 
appendicitis may arise, which, for one reason or another make 
an operation either impossible or inadvisable, as for example, 
if the patient absolutely refuses surgical aid, in spite of know- 
ing the dangers of that course; when surgical aid is not to be 
had or only a very poor variety; in people of great age where 
it is feared the shock of any operative interference would be 
fatal and last but not least important, in those cases which 
have been neglected until general peritonitis is present with 
distention and an almost moribund condition, when operation 
is considered as a last hope. These last-named cases almost 
invariably die if operated upon and are likely to die if they 
are not, but a few may survive careful medical treatment. 
Of course, it is a matter of very fine distinction and surgical 
judgment when this point is reached and rejection of surgery 
should not be encouraged except after mature deliberation 
and full consultation. 

In all these conditions it will be necessary at times to turn 
to general medical care without operation and the dietary and 
general routine care of such patients are of the utmost impor- 
tance. Formerly in these conditions reliance was placed on 
opium in full doses, and many cases were successfully carried 
through with its aid. The effectiveness of opium depended 
on the fact that it quieted the bowel, tending to stop peris- 
talsis and the consequent transference from the iliac fossa of 
the septic material all over the abdominal cavity, an easy 
matter when peristalsis is active; and no doubt also to the 
fact that it helped to destroy the appetite and so limit dis- 
tention from fermentation of ingested food. Of late years 



APPENDICITIS 361 

this method has fallen into disrepute because of the fact that 
opium so completely masks the symptoms in the early stages 
that one cannot tell of the progress of the disease and one is 
apt to miss the true significance of the patient's condition. 

Ochsner's Treatment for Appendicitis.^ — In the early nineties, 
Ochsner devised the treatment which goes by his name and 
although it has been the storm center of many arguments, 
under the conditions mentioned, where operation is impossible 
or inadvisable, it remains today the best method we have and 
often gives surprisingly good results. In a word, it consists 
of withholding everything by mouth, forbids catharsis and 
insists upon gastric lavage when there is nausea Or vomiting 
and depends upon rectal absorption of small amounts of predi- 
gested food and salines. 

Ochsner bases his recommendation of this method founded 
on experience on these two cardinal facts. 

1. *'The anatomical location of the appendix makes it easy 
to be shut off from the general abdominal cavity, if the sur- 
rounding structures remain at rest for a time.'' 

2. *'If at rest, the cecum, omentum and small intestine sur- 
round the diseased appendix, no matter what its pathological 
condition — so shutting it off from the general cavity." 

The effect of taking food is to excite peristalsis and no matter 
how light the food, it may, by exciting peristalsis, carry septic 
material all over the peritoneum and the gas produced by food 
passing down disturbs an inflamed appendix. He therefore 
forbids absolutely everything by mouth. This doesn't mean 
that a little broth or water or milk may be given, but means 
that at first nothing is to pass the lips. Ochsner further 
states *'no matter whether the patient has a catarrhal appen- 
dicitis with or without a foreign body in the appendix or 
whether the appendix is gangrenous or perforated he will 
almost invariably recover if from the beginning of the disease 
absolutely no food is given by mouth." 

He also insists on gastric lavage if there is nausea or vom- 
iting or if the patient begins his appendiceal symptoms 
shortly after a meal. This removes material that excites 
peristalsis and will later surely ferment and form gas if it be 
not promptly removed. The lavage is to be repeated at least 
once if the nausea and vomiting recur; usually after the first 
twenty-four hours water may be given by mouth in small 
amounts, but if peristalsis is thereby excited it must be given 
only by rectum. 

The last feature of Ochsner's treatment is to give nutrient 

^ Handbook of Appendicitis, 1906, p. 132. 



8G2 DIET IN DISEASES OF THE INTESTINES 

enemata every three to six hours not to exceed 4 ounces at 
a time, made up of J or i ounce of some predigested commer- 
cial food in 3 or 4 ounces of normal saline solution and 
given by a small tube after adding twenty drops of tincture 
opii deodorata, for an adult, to the first feeding and one- 
half that amount to the other feedings (children in proportion), 
unless the patient is entirely free of pain or restlessness. 
These directions are to be followed until the patient is well 
along toward recovery and in very severe cases he continues 
the rectal feeding for ten days or even longer. Theoretically 
there is objection to giving anything by rectum, as peristalsis 
is at once excited in the entire length of the large intestine, as 
is so clearly shown by the fluoroscope when bismuth or barium 
are mixed with the enema. Practically, however, this objection 
does not seem to invalidate the treatment, probably because 
the peristalsis is along definite and fairly fixed lines, unlike the 
movement of the small intestine. 

Of course, as shown in the chapter on Rectal Feeding, these 
enemata furnish little besides fluid, although some protein in 
the form of amino-acids and some of the sugars are absorbed 
in solution. Probably completely pancreatized (*^ peptonized") 
milk (two hours) after being sterilized is quite as efl&cient as 
the commercial predigested foods. 

Ochsner himself is a strong advocate of surgical intervention 
in appendicitis and only recommends the foregoing when an 
operation is either impossible or inadvisable, as already 
explained. 

Chronic or Larval Appendicitis. — In chronic appendicitis or 
larval appendicitis, conditions are quite different from the acute 
variety and while operation is advisable when* a diagnosis is 
made, it may, for one or another reason, be necessary to post- 
pone it until some later time. Then too, when not acutely ill 
it is not always so easy to persuade one's patients to undergo 
the operation, although they should be warned that an acute 
exacerbation is possible at any moment which may make an 
operation imperative. If, on the other hand, it is necessary to 
tide these patients along for one or another reason, dietary 
regulations will help in reducing the symptoms in many 
cases, until an operation can be done. 

In very many of these patients there is an accompanying 
constipation which is more or less marked and in them the 
diet as advised for chronic constipation will be of distinct 
value, for by facilitating the constant removal of fecal masses 
from the colon the congestion of the caput coli and appendix 
region will be considerably reduced, so lessening at all events 
the pain and many of the symptoms of chronic indigestion 



CHRONIC TYPHLITIS AND PERITYPHLITIS 363 

which these patients have, also any pressure on the appendix 
from impinging fecal masses will be relieved. In these patients 
it is advisable to give a morning dose of some one of the saline 
cathartics, at least until the bowels act regularly themselves. 
The following mixture as recommended to the author by R. 
Freeman, has proven its value many times. Sodium salicylate 
5i (8 gm.), sodium phosphate §ss (i6 gm.), sodium sulphate 
Biss (45 gm.), giving a teaspoonful of this combination (more 
or less as required), in the early morning, at least one-half or 
three-quarters of an hour before breakfast. It should be dis- 
solved in a little hot water and the glass filled at least three- 
quarters full with cool, but not cold water. The addition of the 
salicylate salt helps to reduce fermentation and consequent 
distention. The chronic cases with constipation have the 
latter feature lessened by the use of some preparation of min- 
eral oil, provided it does not disagree (see Chronic Consti- 
pation). 

When constipation is not a feature of the condition a diet 
containing the minimum amount of fermentable vegetables 
is advisable, i. <?., leaving out potatoes, onions, cauliflower, 
cabbage, Brussels sprouts, sweets, fresh breads or uncooked 
starches, pies, cakes, syrups, fried foods or foods that are 
famously indigestible (see section on Indigestion). Here, too, 
it is advisable to give a smaller dose of the saline or the above- 
mentioned salts which help to drain the appendix and reduce 
congestion about it. Rest before and after meals is advisable 
and it is especially desirable that these patients should eat 
without haste and thoroughly masticate their food. 

The author has seen many cases in which this plan of treat- 
ment has reduced the symptoms to a minimum and in a num- 
ber relieved the patients entirely, although, of course, it is 
presumable that further trouble will recur at a later time, 
particularly if the appendicitis is of the chronic involuting 
variety. 

CHRONIC TYPHLITIS AND PERITYPHLITIS. 

The dietary routine for these conditions is much the same 
as that given for chronic appendicitis, although here oil and 
fat foods play a more prominent part and the injection of two 
or three ounces of oil in the rectum at bedtime is most useful. 
In some cases it will be necessary to revert to the diets recom- 
mended for chronic colitis of which these conditions are often 
a part. The use of salines is also useful in keeping the caput 
as free of feces as possible, and a moderate dose of a mild saline 
cathartic in the early morning is helpful. 



364 DIET IN DISEASES OF THE INTESTINES 



INTESTINAL AUTO-INTOXICATION. 

The entire subject of auto-intoxication is far from clear, 
particularly in its clinical bearings, and there may be found 
great difference of opinion among biological chemists as to the 
significance of the products of intestinal fermentation and 
putrefaction in their relation to conditions of actual disease 
or pathological states. Thus Taylor^ says that intoxication by 
resorption of the digestive juices by products of normal diges- 
tion and by abnormal products of digestion is not proven 
experimentally and probably does not exist and in ^'normal 
bacterial disintegration of food-stufFs in the alimentary tract 
no known toxic substance is found," for the products of carbo- 
hydrate fermentation, formic, acetic, butyric, valerianic pro- 
prionic, lactic, succinic acids and a trace of oxalic acid are 
not toxic. So too, according to Taylor, although protein 
putrefaction yields phenol, skatol, indol and cresol from animo- 
acids and hexone bases, none of these are toxic. Also there is 
''no constant relation between the protein ration and the out- 
put of aromatic substances, and a high urinary output of 
aromatic substances indicates active putrefaction in the 
colon, which may be innocuous or not. On the other hand, a 
low output need not indicate a low degree of bacterial activity 
in the intestines and need not speak against a bacterial intes- 
tinal intoxication. 

Cytolytic degeneration seems allied to the process of fer- 
mentation, the functions of the tissues are disturbed by the 
cytolyses and an auto-intoxication may result, also the prod- 
ucts of tissue degeneration may be toxic themselves, so that 
according to Taylor again it is not possible to separate auto- 
intoxication from the general pathology of metabolism. 

In so-called gastro-intestinal auto-intoxication there is no 
constant relation, according to the same authority, between 
constipation, excess of indican and conjugate sulphates in the 
urine, nor does the degree of these substances bear any relation 
to the severity of the symptoms. 

Combe,2 on the other hand, is an enthusiastic supporter of 
the gastro-intestinal origin of certain toxic states of the organ- 
ism and marshalls his proofs in very clear and logical order. 
We all know that bacteria play a large part in the digestive 
processes and the questions are asked: 

1. Is the microbic intervention useful to the body.? 

2. Is it indespensible.? 

3. Can it become harmful.? 

^ Osier's Mod. Med., vol. ii, 503. 
2 Auto-intoxication. 



INTESTINAL AUTO-INTOXICATION 365 

1. The answer to the first is positively affirmative, as the 
bacteria digest foods as do the enzymes and in some instances 
digest portions of the food (cellulose) which the enzymes cannot. 

2. The bacteria are also indispensable as proven by Nuttall, 
Thierfelder^ and Schottelins^ who showed that animals born 
and raised aseptically did not thrive or, in many instances, 
live at all. 

3. In answer to the third question as to the possible harmful 
qualities of bacteria in digestion. Combe gives positive assent, 
although it has been strongly combated by the German 
school, who admit the symptomatology and the probable 
focus but find the proofs insufficient. He further fortifies his 
position by pointing to the autotoxic and detoxifying powers 
of Nature's three lines of defense against intoxication found in 
the intestinal epithelium, liver, glands of internal secretion 
and external secretion as, e. g., the kidneys, through which 
intestinal toxins are constantly eliminated. 

Phenol, indol and skatol are all formed in the intestine as a 
result of putrefaction of nitrogenous food-stuffs, principally 
meat. Phenol is formed in the large intestine as a result of 
bacterial activity in the presence of stasis there, but when 
small in amount is oxidized in the organism or is eliminated 
by the bowel and only when the formation exceeds the oxidiz- 
ing powers is it excreted by the urine. Indol is formed in the 
small intestine as a result of stasis in this part of the bowel 
and never when the stasis is in the large intestine. It is oxi- 
dized into indoxyl, which combines with sulphuric acid in the 
liver to form indoxyl sulphuric acid; this appears in the urine 
as a salt of potassium, potassium indoxyl sulphate or indican. 
This substance in turn is oxidized into sulphuric acid and 
indoxyl, the latter into indigo red or indigo blue if an oxidizer 
is present. 

Both indol and phenol excretions depend on: 

1. The composition of the food (which varies). 

2. On the degree of peristalsis. 

3. On the power of absorption. 

4. On putrefaction intensity.^ 

It is strongly disputed whether indicanuria has any effect 
in producing symptoms of so-called auto-intoxication but there 
seems little doubt but that it is at least the index for other 
conditions which result in symptoms, and the association of 
marked indicanuria and evidence of renal irritation (as a trace 
of albumin, casts, etc.), is too definite to be dismissed without 

^^Ztschr. f. phys. Chem., vol. xxii, 71. 

2 Arch, fiir Hyg., vol. xxiv, 210. 

3 Combe: Auto-intoxication, p. 6j. 



366 DIET IN DISEASES OF THE INTESTINES 

adequate explanation, particularly as relieving the indicanuria 
often results in a return to a normal urinary output. The 
effect of the indican perhaps while not deleterious in itself 
may be to cause renal irritation and consequent reduction in 
the kidneys' power for excretion of other toxic substances at 
present unknown but standing in a causal relation to the 
symptoms of intoxication. At the same time there is no end 
of clinical evidence that when symptoms of a toxemia are 
present in connection with considerable amounts of indol in 
the urine, relief is seldom or never obtained until measures 
are adopted to restrict its formation (diet) and to favor its 
elimination (catharsis and intestinal irrigation). 

On the other hand, there are undoubtedly many cases of 
indicanuria which are entirely without symptoms, so that 
while the specific variety of auto-intoxication depends on chem- 
ical, physiological and pathological facts too intricate to be 
as yet made out with clearness and it is not possible to speak 
of treatment based on specific etiological factors, we know 
something of the course of development of the intestinal poi- 
sons from fermentation and putrefaction^ and the clinical con- 
ditions that lead directly to it, as well as the factors that 
modify it. 

Dyspepsia and stasis either gastric or intestinal; diseased 
conditions of the intestinal walls with consequent lessening of 
the defense mechanism; parasites; diminished activity of the 
antitoxic organs; bad eating habits, hurry, working too soon 
after a meal, all may be of etiological importance. 

Dietetic Indications for Intestinal Auto-intoxication. — When 
one comes to consider the necessary factors in diminishing 
nitrogenous intestinal putrefaction one finds that Combe^ sums 
up the indications as follows: 

1. Modify the intestinal culture medium in which the pro- 
teolytic bacteria thrive by. 

(a) Introducing an antiputrefactive lactofarinaceous diet. 

(b) Introducing antagonistic bacteria into the intestinal 
medium. 

2. Diminish the vitality of the proteolytic bacteria in the 
intestine by means of germicidal medicines (there is as yet no 
known way to accomplish this satisfactorily). 

3. Evacuate the proteolytic bacteria and their products by 
intestinal lavage. 

The first indication, namely, that of modifying the culture 
medium is the one with which we are particularly concerned 
and leads us to a study of diet for this condition. 

^ Forchheimer: vol. ii, 664. ^ Combe: Auto-intoxication, p. 234. 



INTESTINAL A UTO-INTOXICA TION 367 

General Indications for Diet: 

Nitrogenous Foods. 

1. Diminish these as much as possible, keeping to the low 
level of physiological requirement, 40 to 60 gm. (i| to 2 oz.) 
of protein, per diem. 

2. Absolutely prohibit those forms of nitrogenous foods 
that favor the development of putrefactive bacteria, e. g., 
meat. 

3. To choose among these milk in one of its many forms, 
whole, skimmed, zoolak, koumyss, buttermilk, kefir, cream 
or pot cheese. 

Fatty Foods. 

1. Avoid meat fat as increasing putrefaction. 

2. Give fat best in the form of fresh butter and cream. 
Farinaceous Foods. 

1. Give as large a proportion of farinaceous foods as pos- 
sible, saturate the intestines with them, giving five or six meals 
in the proportion of five times as much farinaceous as protein 
foods, whenever the latter are given. 

2. In auto-intoxication from acute enteritis an exclusive 
farinaceous diet must be given for several days. 

3. In auto-intoxication due to chronic enteritis, the diet 
should be lactofarinaceous giving later a little meat or eggs. 

4. In ordinary auto-intoxication milk mixed with fari- 
naceous food is best, for the lactose of the milk on account of 
its lactic acid-forming abilities is a strong antiputrefactive 
element.^ 

Foods to Especially Avoid. — Bouillon, meat soups, meat 
juices and jellies, meat extracts, white of egg or dishes which 
are made of it. Milk, unless mixed with farinaceous food. 
High or tainted meats or those which decompose rapidly, 
game, rare or raw meats, fish, shell fish. 

In severe auto-intoxication absolutely no meat should be 
taken and when it is begun later, only in small progressive 
quantities, not forgetting that it should be taken with five 
times its bulk of farinaceous foods. 
Foods to take. 

Fruits raw or cooked. 

Vegetables, thoroughly cooked and soft, all farinaceous 
foods, as rice, noodles, macaroni, puddings, puree of vegetables, 
bread, yolk of eggs. Sauerkraut is a valuable antiputrefactive 
food. 
Modified Sample Menus. Farinaceous without Meat. 

7.30 A.M. Cereal prepared with water or milk. Rolls and 
fresh butter. 

10.00 A.M. Some form of gruel made with milk or water. 

^ Combe: Auto-intoxication. 



368 DIET IN DISEASES OF THE INTESTINES 

12.30 P.M. One or two yolks of eggs, raw or boiled, maca- 
roni, rice, farina with salt and fresh butter. 
Farinaceous pudding. Rolls and butter. 
(Later fruit and soft green vegetables.) 
3.30 P.M. The same as at 10.00 a.m. 
7.00 P.M. Same variety as at 12.30 p.m. 
10.00 P.M. Infusion of chamomile, peppermint, fennel, 

or anise. 
After eight to ten days of this, add potatoes, puree or baked. 
Whortleberry juice or jelly. No fluids with meals. 

Later tea, coffee, cocoa, vegetables, and fruits, may be 
added in the order named with a little meat, first at one and 
then at two meals, watching the effect. 

In choosing a diet one must also be somewhat guided by the 
conditions so often associated with intestinal auto-intoxication, 
e. g.y stasis, chronic constipation, torpid liver or actual hepatic 
disease and circulatory disorders. 

A sample diet covering the most usual associated condition, 
viz., that of chronic constipation or intestinal stasis might be 
chosen somewhat as follows: 

Early morning, one-third or one-half glass of grape juice 
with equal amount of water. 

Breakfast: Glass of milk or buttermilk with cereal and 
cream (tea or coffee later). Bread and fresh butter. 
Fruit. 
Midmorning: One-half glass of buttermilk and slice of 

bread. 
Dinner or Supper: Cream vegetable soup made without 
stock or thickened with flour. Yolk of two or three 
eggs poached or scrambled; macaroni, cream cheese, 
potato, rice, baked farina, green vegetables (that grow 
above ground). Glass of milk or buttermilk. Bread 
and fresh butter. Farinaceous pudding with fruit 
sauce or stewed figs, prunes, apricots, pears, cherries 
or peaches. 
Midafternoon: Cream cheese and crackers. 
At Bedtime: One-half to one glass of buttermilk with two 
or three toasted crackers and several dates or figs. 
This should be kept up for a long enough time to get rid of 
the subjective symptoms and any abnormal urinary findings, 
and then little by little one may add a little meat and other 
foods, gradually returning to a normal dietary but for a long 
time keeping the protein at a low level as already indicated 
before. 

The treatment should be begun with a mecurial purge and 
the use of some laxative or mineral oil continued for some 



HIRSCHSPRUNG'S DISEASE 369 

time. When the symptoms are severe great assistance is 
obtained from high colon irrigations with normal saline or a 
I per cent, solution of ichthyol. 

General bodily exercise regularly every day and hygiene are 
all of great assistance in ridding the gastro-intestinal tract of 
the toxic materials. 

In some instances a complete change of life, a trip to Europe 
or elsewhere, taking the patient out of his usual routine may 
be necessary to accomplish the end desired. The usefulness 
of this has been proven more than once in the writer's 
experience. 

HEMORRHOIDS. 

Hemorrhoids are caused by a dilatation of one or more of 
the veins at the anal ring which at any time may be throm- 
bosed. The dilatation is due either to a temporary and local 
obstruction to the return venous flow, as in constipation, or 
fecal impaction, or just mere straining at stool, or to a per- 
manent interference with the return flow, as seen in cirrhosis 
of the liver or chronic cardiac disease. 

The dietary prevention of the temporary venous obstruc- 
tion is very important and one can do much to obviate the 
production of hemorrhoids by giving a diet which will be 
laxative such as is recommended in chronic constipation, 
including as it does a large amount of cellulose in green vege- 
tables and fruits, fresh and dried; oils, fats and liquids in 
excess. 

When the hemorrhoids develop as a result of straining and 
tenesmus in prolonged diarrhea, a diet to control the loose- 
ness will be of use as in chronic diarrhea, unless one can find 
the direct cause of the diarrhea and correct it. 

In the cases of hemorrhoids dependent on hepatic or cardiac 
disorders it will be necessary to insure regular bowel move- 
ments, using an anticonstipation diet so far as one can in 
consideration of the underlying causes-. Measures directed 
toward the relief of the hepatic or general intestinal conges- 
tion are necessary in addition to the suitable diet. 

HIRSCHSPRUNG'S DISEASE. 

In this disease, which is a chronic or congenital dilatation 
of the colon, there are certain dietary indications which are 
designed to combat rather the symptoms (which are often 
secondary to the condition, such as chronic constipation and 
stasis with at times symptoms of toxemia) than the dilatation 
itself. There is one exception to this, namely, that foods which 
24 



370 DIET IN DISEASES OF THE INTESTINES 

are particularly prone to be stored up in the colon and increase 
the dilatation should be avoided, as for example an excess of 
tough cellulose. 

The diet recommended for chronic constipation is best 
suited to this disease with the precaution that all vegetables 
and fruits should be soft when fed and not given in indiges- 
tible bulk, although the total quantity of such foods should be 
great. 

It would seem as if in this disease the regular use of mineral 
oil might accomplish much by its lubricating qualities, and 
certainly deserves a trial, which, with massage of the colon, 
may help to preserve the muscular tone of the intestine. 

A surgical procedure is the only permanent way of relieving 
Hirschsprung's disease, either as a colectomy or iliosigmoid- 
ostomy. 



CHAPTER XXII. 

DISEASES OF THE ACCESSORY DIGESTIVE GLANDS. 

The action of these glands and their secretions are so indis- 
solubly connected with the processes of digestion, that the 
consideration of one imphes consideration of both. We have 
dealt with dietetics of diseases of the digestive tube separately, 
but as a matter of fact, unconsciously we are compelled to 
take account of the state of the accessory glands in doing so, 
and of making allowances for their integrity or lack of it. 
On the other hand, there are certain diseases or pathological 
states of these glands that arise, which demand attention aside 
from the questions of digestion, as well as the bearing of these 
conditions on the normal utilization of food-stufFs, and with 
some of these we are now particularly concerned. 

DISEASES OF LIVER AND GALL-BLADDER. 

It is much to be regretted that the dietetics of hepatic dis- 
eases cannot be more serviceable as curative agents and still 
more to be regretted that most people are not willing to exer- 
cise the common sense and self-restraint in drinking and eat- 
ing, the failure of which in so large a measure is responsible 
for the frequency of diseased condition in these organs. 

In other words, dietetics here are much like locking the 
stable door after the horse has been stolen, for the dietetic 
prophylaxis is all important. After the damage is done patients 
are willing to go anythwere and spend any amount to be rid 
of their troubles or dq anything that offers a chance in the 
prevention of a return or continuance of their symptoms. 

In the matter of diets for hepatic disorders and disease we 
could act a good deal more intelligently if we had a simple 
and reliable method for testing hepatic functions, for if our 
choice of a diet could be made to depend on definite knowledge 
of just what food elements were poorly metabolized by the 
liver, we could choose a diet especially adapted to the indi- 
vidual case. 

The methods in vogue for testing liver functions are too 
uncertain or too complicated to be of much practical use, 
although there is no doubt but that there is progress being 
made in this direction. 



372 DISEASES OF ACCESSORY DIGESTIVE GLANDS 

Strauss used lOO to 150 gm. levulose to test liver functions, 
a resulting levulosurea indicating a disturbed hepatic func- 
tion. As a matter of fact, most diseased livers respond to 
this test, but in many of the cases of cirrhosis the glycogenic 
function is perfectly well preserved and we get no resulting 
levulose in the urine. 

Opie^ found that when the liver was poisoned by certain 
substances as, e. g., chloroform, the susceptibility to intoxica- 
tion is greatest after a diet of fats, less after meats and least 
in animals fed on carbohydrates. This by analogy can be 
used in choosing the diet in threatened cholemic states where 
the liver cells are failing in their power to functionate, over- 
whelmed as they are by the poisons in the system, here 
carbohydrates should be given fully and may even be given 
subcutaneously, as a 5 per cent, solution of glucose. 

Dietetic Prophylaxis. — This question is practically a state- 
ment of the etiology of many abnormal liver conditions and 
while it is to be feared that few wdl heed advice until experi- 
ence has taught its bitter lesson, it is certainly a necessary 
thing to state how most of these diseases may be avoided, 
excepting of course those due to direct infectious agencies. 

It is only necessary to remind the reader of the physiology 
of the liver to see that almost everything absorbable that is 
ingested finds its way sooner or later to the liver, which is 
endowed with extraordinary powers. These powers may be 
spoken of as the detoxifying, lipogenic, glycogenic and urea- 
forming functions. In a normal liver these operate to perfec- 
tion, but in disease are more or less disturbed or permanently 
disabled. For the exact mechanism by which this is accom- 
plished, one is referred to Physiology, and all that is neces- 
sary here is to enumerate the *'don'ts" of dietetics to point 
the way to a preservation of normal functioning. 

The excessive ingestion of any one of the food elements, 
protein, carbohj^drates and fat will lead eventually to disturbed 
liver function, and a continuance of this results in permanent 
damage to the cells. Among the articles of food especially to 
be avoided are condiments of all sorts, alcohol, vegetables rich 
in irritating oils, such as garlic, radish and horse-radish and 
the continued use of phosphorus or arsenic in course of treat- 
ment. This does not mean that one must go through life 
without the use of any condiments, for a little at times can 
be successfully detoxified by the liver, but taken in large 
amounts or continuously they form a very distinct danger to 
the integrity of the cells by chronic irritation and the produc- 

1 Jour. Exp. Med., 1914, xxi, l. 



DISEASES OF LIVER AND GALL-BLADDER 373 

tion of connective tissue. Alcohol is, of course, the chief 
offender and it hardly seems necessary to mention this point, 
it is so generally known and recognized even by the laity. 
Spirits as whisky, gin, brandy, etc., are especially bad and all 
other alcoholic drinks directly in proportion to their alcohol 
content. When taken on a full stomach and largely diluted 
they are of course, least irritating, but the dilution does not 
lessen the absorbability of the alcohol but merely spreads it 
over a longer time, giving the liver a better chance to handle 
it. Especially bad are undiluted spirits on an empty stomach, 
as cocktails or neat spirits taken as an appetizer before meals, 
as here the absorption is quickest and most complete and is 
apt to be regularly repeated. While the spirits have a tendency 
to produce cirrhosis, the beers do so also, but to less extent, 
and their damaging effects are seen as well in the deposition 
of excessive amounts of fat in and about the liver cells and as 
a fatty degeneration of the cell itself. 

Acute Hepatic Congestion. — This is caused frequently by 
overeating and drinking and from a dietetic point of view 
requires starvation or semistarvation until the appetite, which 
is usually completely lost, returns. During this day or two of 
starvation water can be given freely, and as soon as the patient 
is able to take food he may be given small amounts of milk 
skimmed or whole, diluted with alkaline waters; also gruels, 
cream soups, milk toast and soft cereals, custards, soft green 
vegetables, chicken, and so back gradually to full diet, giving 
the articles in about the order listed. 

This condition of acute congestion of the liver is usually 
designated by the layman as a *' bilious" attack, at all events 
that covers the situation, although nobody knows just what a 
*' bilious" attack is, it seems to be so many things to different 
people. 

Acute Catarrhal Jaundice or Gastroduodenitis with Jaundice. 
— In this condition we have not only the catarrhal inflammation 
of the bile ducts but primarily of the stomach and duodenum, 
so that the catarrh of this part of the digestive tract must be 
taken into account in the choice of a diet. Fortunately the 
same diet fits both conditions. As fat is very badly digested 
in this, it is best to reduce it to a minimum until the jaundice 
is largely over; to this end skimmed milk is an ideal diet, 
although here again a day or two of starvation at the outset 
may be quite the most serviceable procedure, provided water 
is given in large amounts. After the skimmed milk we can 
give broth, gruels and soft foods generally in progressive 
order. An early morning saline laxative is essential, particu- 
larly when constipation is marked, but all cases are benefited 



374 DISEASES OF ACCESSORY DIGESTIVE GLANDS 

by it, as it has a favorable influence on the gastric and duodenal 
catarrh. According to Forchheimer jaundice causes a hyper- 
chlorhydria in direct proportion to its intensity, and the diet 
must be chosen with this in view, avoiding stimulating acid 
or irritating foods. 

Chronic Hepatic Congestion. — This is usually passive and 
due to cardiac disease with failure of compensation. The diet 
should be light, non-stimulating and attention directed to the 
cause of the congestion. 

Portal Cirrhosis. — Although this disease does occur occa- 
sionally in children and young adults without known cause, 
it is for the most part, par excellence, the disease of retribu- 
tion and can usually be traced to chronic hepatic irritation 
from overindulgence in irritating foods and drinks, especially 
alcohol. Where the diagnosis is fairly certain and especially 
in the earlier stages, it is necessary to institute at once a rigid 
milk cure (as milk is nourishing and absolutely non-irritating), 
given continuously and alone for from four to six weeks,^ 2 or 
3 quarts per diem, diluted with soda water, Vichy or Apolli- 
naris or flavored with tea, coflPee or cocoa. This diet reduces 
intestinal putrefaction to a minimum, so causing less hepatic 
irritation, the fat is in emulsion and absorption can take place 
in spite of an intestinal catarrh. ^ When nausea or vomiting 
are sources of trouble, skimmed milk often agrees better than 
whole milk.^ 

After this period of milk diet one may add eggs, gruel, 
cereals, fresh green vegetables, stewed fruits. Much sugar is 
forbidden, as it is apt to cause fermentation, fats too, often 
give rise by fermentation to the formation of acetic, lactic or 
butyric acids and should be avoided. 

After a month of this diet Osier recommends a return to 
the milk period again for a time, alternating with the addi- 
tional diet as indicated. Of course all the foods that belong 
to the irritating class are to be permanently vigorously 
avoided. Besides those already mentioned one must include 
meat or strong meat broths, neither of which should be taken 
for a long time in order to keep the production of urea down 
to the minimum. 

Occasionally the milk may be advantageously given in the 
form of the Karell cure, particularly if the cirrhosis is compli- 
cated by ascites. The low salt content of this diet (1.3 gm. 
per day) acts as one of the salt-poor diets does in nephritis 
and often helps in the removal of the fluid, at least in part. 

1 Osier's Modern Med., vol. iii, 444. 

2 Rolleston: Diseases of Liver, p. 297. 

3 Herter Lectures on Chem. Path., 1902, p. 88. 



DISEASES OF LIVER AND GALL-BLADDER 375 

Einhorn recommends duodenal feeding in cirrhosis on 
account of its sparing the portal congestion, reports on its 
usefulness are, however, meager. 

Biliary Cirrhosis. — Here we have more often an extension, 
via the bile ducts, of a direct infection of the biliary system, 
the cause often originating in the intestine. 

The diet is much the same as that recommended for portal 
cirrhosis, although the milk diet may not need to be so rigor- 
ously or so long continued. Constipation must be especially 
combated and is best managed by a morning saline laxative. 
After the milk period of feeding is over we may give sago, 
zweiback, rice, potato, fish, chicken, etc., avoiding all the 
irritants as in all other diseased states of the liver. 

Fatty Liver. — Since the chief cause of fatty infiltration of 
the liver is the excessive ingestion of alcohol or fats, the natural 
recommendation for prophylaxis would be to take less or 
none of either. The fatty degeneration of the liver will hardly 
be affected by diet, except as it may modify the acute infec- 
tion which is the cause of the degeneration. 

As a matter of fact fatty infiltration and degeneration usually 
go hand in hand; one or the other predominating, depending 
upon the etiological factors. 

When one has a well-developed case of fatty liver due pri- 
marily to infiltration, it is necessary to oversee the patient's 
diet with great care. If the individual is obese it will be 
necessary to institute a reduction diet cure combined with 
suitable exercises (see Obesity). In this way a certain amount 
of excess fat can be removed in the general course of reduction 
and with the improvement in the patient's general condition 
in consequence of this it is also probable that the fatty infil- 
tration will become less marked unless it has already gone on 
until the liver tissue has become very fat, as occurs in the more 
severe cases. 

Overeating and alcohol are especially to be forbidden, 
although this is true, too, of all the conditions already 
described. Fat food must be interdicted and only a moder- 
ate amount of carbohydrate allowed. In hot climates a 
vegetable diet with milk is particularly recommended. Where 
there is fever, meat must be restricted, otherwise it may 
be allowed in moderation,^ and ail the lighter proteins are well 
borne, as fish, eggs, milk and cheese, if not too rich. As has 
been already said, when the fatty liver is part of a general 
adiposis the patients must be treated as for obesity with the 
hope that much of the excess of fat can be gradually removed 

^ Quincke, Hoppe, Seyler: Die Kranldieit d. Leber, p. 122. 



376 DISEASES OF ACCESSORY DIGESTIVE GLANDS 

as the patients return more nearly to their normal condition 
and weight. 

Acute Yellow Atrophy of the Liver. — Since the admitted 
cause of this condition is a toxemia, not always due to the 
same agent, the treatment consists in prophylaxis so far as 
possible. Any form of jaundice, therefore, particularly that 
occurring in a pregnant woman, should always be viewed with 
suspicion. 

When the condition has been diagnosed the diet plays a not 
inconsiderable part in the treatment and since there is apt to 
be an acid intoxication present the giving of cereal gruels 
other than oatmeal is important, which with milk should form 
the basis of the diet. The drinking of a large amount of an 
alkaline water or even plain water, to which sodium bicar- 
bonate is added or not, is recommended by Kelly. ^ 

Amyloid Liver. — ^The etiological factor in this disease is 
some focus or foci of chronic suppuration, and the diet should 
be constructed with an idea of increasing the food consumption 
to the maximum, compatible with health, in order most suc- 
cessfully to combat the chronic infection, which should, of 
course, be treated surgically if possible. All fat foods, such as 
cream, butter, fat meats; concentrated carbohydrate foods, as 
breads, cereals, macaroni; sugars and honey are especially 
good. The protein of the diet should be increased to approxi- 
mately 120 gm. if the patient can take this amount, for com- 
bined with exercises this amount of protein will favor the 
formation of tissue and thus increase the active protoplasm. 

Cholelithiasis. — From the dietitian's point of view nothing 
can be done to aid in the removal of gall-stones when already 
formed, although much has been written on the possibility of 
dissolving gall-stones in situ. Their partial disintegration and 
occasional complete disappearance does take place experi- 
mentally, when gall-stones are placed in a dog's bladder, 
either in its normal condition or when an experimental inflam- 
matory condition has been produced in the gall-bladder, but 
this is very different from the conditions under which the 
stones form in the human subject and when formed seldom, 
if ever disappear spontaneously. This does not mean that the 
gall-stones may not "go to sleep" so to speak, and remain 
quiescent for years or permanently, as this often happens in 
the experience of every physician. While diet has little or 
nothing to do with the disappearance of stones when alread}^ 
formed, it has much to do with their formation in the first 
place, and still more to do with their recurrence after opera- 
tion, for statistics show that a fair number of patients in whom 

^ Osier: Modern Medicine, vol. iii, 477. 



DISEASES OF LIVER AND GALL-BLADDER 377 

the gall-bladder is not removed at time of operation suffer 
from recurrence of gall-stones. 

Naunyn, Kehr, AschofF and others regard the formation of 
gall-stones as merely an incident in disease in which infection, 
bile stasis and inflammatory manifestations are the principal 
things^ and it is against these factors of disease that dietetic 
treatment should be directed, rather than against their results. 
Dietetic indiscretions, long continued, that lead to catarrh of 
the stomach, duodenum and gall-bladder tend to produce gall- 
stones indirectly by affording means for the access of bac- 
teria^ to the biliary tract, so that little need be said to press 
home the importance of diet as a preventive measure. 

While a large majority of gall-stones are formed of choles- 
terol, almost every one has at its center a bacterium of one 
sort or another, so that infection is perhaps the first and chief 
necessity in the production of stones. Lime salts are fre- 
quently superimposed on the cholesterol stones, as well, and 
bile pigments, particularly bilirubin, form part of many stones. 

Prophylactic or Postoperative Diet. — There are no new prin- 
ciples involved in choosing a diet to prevent reformation of 
gall-stones, and with certain exceptions it is probably as much 
a matter of the quantity of food ingested as the quality. These 
exceptions will, of course, include all foods or drinks that tend 
to produce gastro-intestinal catarrh or those which have a 
direct effect on the liver cells, by virtue of their intrinsic 
irritating character and the fact of their being carried directly 
to the liver by the portal system. Such foods and drinks 
have already been spoken of in connection with portal cir- 
rhosis and include condiments as peppers, mustard, curry, 
spices, salty foods, alcohol in all forms and very hot foods or 
drinks and ice-water in large amounts. 

Meats. — Only easily digestible meats should be taken and 
"high" meats, pork, fatty meat and fish, such as goose, duck, 
mackerel and blue fish should be avoided. 

Fats. — Some dietitians condemn the use of all fats, but there 
does not seem to be any reasonable basis for such complete 
prohibition. Fat is an essential food element and is a necessary 
part of any mixed diet. What should be avoided is fat that is 
particularly indigestible, such as all those that melt only at a 
higher temperature than the body, e. g., mutton fat, salt fat, 
as bacon or pork, or exce'ss of even simple fat is to be avoided. 
There is no objection to sweet butter, cream in moderation 
and vegetable oils and meat fat in great moderation that has a 
low melting-point, as beef fat. 

1 Anderson: Canada Med. Assn. Jour., 1914, iv. 

2 Osier: Mcdern Medicine, vol. iii, 444. 



378 DISEASES OF ACCESSORY DIGESTIVE GLANDS 

Carbohydrates. — Sugar should be restricted as liable to fer- 
ment and cause indigestion; pies, preserves, candy, rich cakes, 
syrup, etc., are all to be avoided. Aside from these restric- 
tions one may eat almost anything provided it is not in exces- 
sive amounts, sufficient to cause overloading of the digestive tract. 

All means to stimulate the flow of bile are especially indi- 
cated and to this end it is often better to give five small meals 
a day, than three larger ones, as each time food is taken, 
bile is expressed from the gall-bladder. 

Vegetables and Fruit. — All vegetables that do not ferment 
are allowable but the cabbage family, radishes, horse-radish 
are barred, also according to Tibbies^ peas, beans, lentils and 
carrots as containing phytosterol, a vegetable form of choles- 
terol, the principal constituent of gall-stones. Fruits that are 
not too sour may be taken, but they are possibly better borne 
stewed with a little sugar. 

Exercises. — Exercises that tend to stir up the liver are all 
good, such as horseback riding and calisthenic exercises which 
include bending and compression of the liver area. 

Alcohol. — ^As already stated patients are better off without 
any alcohol whatever, but when it is insisted upon, they may 
take light Rhine wines, well diluted with an alkaline water, 
such as Vichy, and only with meals and in the greatest moder- 
ation. Not over 3 or 4 ounces of wine with one meal a day. 
Spirits, all forms are particularly bad as tending to produce 
a catarrh of the stomach and intestines, besides irritating the 
liver cells. 

Acute Cholecystitis and Colic. — During the attack usually 
nothing can be taken by mouth, often not even water. Later 
when the stomach is not rebellious, one had best begin with 
milk diluted with an alkaline water, Vichy, soda or Apollinaris. 
This should be kept up until all signs of inflammatory reac- 
tion have disappeared, although possibly thin cereals may be 
begun awhile before this, but milk should form the basis of 
the diet. Later solid food may be taken as outlined in other 
hepatic conditions. Here again a mild saline cathartic 
should be given in the morning regularly for a time, as recom- 
mended for catarrhal jaundice and to which a small amount 
of sodium salicylate may be added to promote the flow of 
bile; possibly the sulphates are best for this laxative purpose. 

In all forms of gall-bladder disease from cholecystitis to 
stone there is great necessity for drinking water very liber- 
ally, and patients should be given a definite amount of water 
to take in the twenty-four hours. 

1 Tibbies: Food in Health and Disease, p. 384. 



PANCREATIC DISEASE 379 



PANCREATIC DISEASE. 

The point at which disease of the pancreas touches dietetics 
is when the function of the gland is interfered with, so that 
we find an insufficient, deficient or excessive secretion. Here- 
tofore it has been possible only to arrive at abnormal condi- 
tions of the secretion by watching the effects on food diges- 
tion, and numerous tests sprang up for determining which 
element of the secretion was deficient, so we had tests for 
tryptic digestion, that for pancreatic amylase and pancreatic 
lipase. Since the introduction by Einhorn of the duodenal 
tube it is possible in many cases to obtain samples of pan- 
creatic juice, sufficiently large for chemical analysis and to 
make satisfactory biological tests of its digestive capabiHty. 
Einhorn and Rosenbloom^ have done this very satisfactorily 
from a clinical stand-point and have determined the composi- 
tion of the normal pancreatic juice. There are variations in 
the secretion of a purely functional nature, as well as varia- 
tions due to pathological changes. Deficiency of trypsinogen 
produces azotorrhea or meat indigestion, lessened lipase a 
steatorrhea or fat indigestion, and diminished amylopsin 
results in carbohydrate fermentation. When we have a new 
growth or interference with the pancreatic internal secretion, 
pancreatic diabetes is the result with an alimentary glycosuria 
and hyperglycemia. 

Still another result of pancreatic and intestinal disturbance 
is the production of that curious condition of arrested develop- 
ment known as infantilism, where the subjects develop men- 
tally, but physically they do not increase much in size, although 
they may take on the adult characteristics. Besides a disturb- 
ance in pancreatic secretion in infantilism the intestinal flora 
is an entirely abnormal one. 

Acute Pancreatitis. — In acute pancreatitis there is usually 
little time to resort to diet for the patients are for the 
most part in shock. If they survive this initial period, 
then they may continue to improve, in which case diluted 
milk, gruels, and other liquids (without meat stock) and fari- 
naceous foods generally may be added to the diet, and later 
chicken and soft vegetables. 

Chronic Pancreatitis. — Here the pancreatic secretions may 
be disturbed in any one of the directions indicated, i. e., there 
may be a failure or diminution of the trypsinogen, steapsin or 
amylopsin with resulting characteristic evidences of this fail- 
ure in the so-called pancreatic indigestion. It is here that we 

1 Arch. Int. Med,, December, 1910. 



1380 DISEASES OF ACCESSORY DIGESTIVE GLANDS 

are apt to encounter the cases of marked steatorrhea charac- 
terized by stools with yellow masses of fat, fluid or semi- 
solid, which if not accompanied by jaundice may amount to 
an average loss of 64 per cent, of the ingested fat. If there is 
mild jaundice the loss will be greater (72 per cent.) and if the 
jaundice is marked and bile is completely shut off the loss 
will amount to 87 per cent.^ Naturally when this condition 
obtains the diet must be made up almost exclusively of carbo- 
hydrate and easily digestible protein, although by giving arti- 
ficially prepared pancreatic extract it is usually possible to 
give a minimum amount of simple fat. In this form of pan- 
creatic deficiency sweetbreads, lean meats, cheese, fowl, 
breads, macaroni, baked potato, rice and other cereals, sugars, 
soft vegetables and fruits only if there is no accompanying 
diarrhea, which is regularly present in the cases of extreme 
deficiency of steapsin. 

When there is a diminution or absence of trypsinogen we 
find azotorrhea present, in which condition striated muscle 
fibers can be found in the stools, a condition often associated 
with marked intestinal putrefaction of protein and with an 
accompanying indicanuria. Under these circumstances the 
diet should be largely carbohydrate with some fat in the form 
of butter, eggs and thin cream. Milk will be fairly well digested 
if the gastric secretions are approximately normal, or failing 
this the deficiency in trypsinogen may be supplied again by 
the pancreatic extract. Cream cheese may also be used to 
supply protein, besides the vegetable protein. All forms of 
farinaceous foods may be used in large amounts together with 
soft green vegetables and stewed fruits. In fact almost any 
food low in protein will be well digested. 

When the amylase is deficient in the pancreatic secretion 
marked fermentation of the stool will take place in the fer- 
mentation tube, so that here it is necessary to reduce the 
starches to the minimum and give them preferably malted or 
with a diastatic ferment to compensate for the loss of the 
natural ferment. 

In the condition of achylia of the stomach the starch in 
moderate amount will be digested by the ptyalin of the saliva, 
but with normal or increased gastric acidity, this is soon 
stopped and the starches pass into the intestine imperfectly 
dextrinized. 

In selecting a diet for these cases any of the simple fats and 
protein foods may be given, but the carbohj^drates best toler- 
ated are those partly malted, as malted breakfast food, toast 

^ T. Brugsch: Lchrbk. klin. Untersuch. Method., p. 371. 



PANCREATIC DISEASE 381 

dried to a brown crisp, dry and partially malted cereals in 
flakes. Next best are fine cereals well-cooked, such as farina, 
wheatena, cream of wheat and well-boiled rice. Potato and 
breads are best left alone unless each meal is followed by some 
artificially prepared diastase and this may be necessary even 
with the carbohydrates already partially prepared by previous 
malting. 

Where the internal secretion of the pancreas is disturbed 
and we have a glycosuria the diet must be in accordance with 
the dietary principles recommended for diabetes mellitus, 
although here, too, artificial diastase helps in the starch diges- 
tion. But these cases are practically diabetics and should be 
so treated. 

In carcinoma, cyst or other pancreatic disease the diet should 
be chosen with reference to the functional integrity of the 
gland or the lack of certain of the digestive elements, as we 
have just seen in chronic pancreatitis. 



CHAPTER XXIII. 

DIET IN DISEASES OF THE SKIN. 

In order to prescribe a rational diet for any disease it is 
necessary to understand its etiological factors, at least to 
some extent. It is therefore unfortunate that thus far there 
are very few skin diseases in which any definite general meta- 
bolic changes are known. With the skin lesions caused by 
parasites, irritants, etc., we have as dietitians no concern, as 
food plays no part either in their production, course or cure. It 
has long been the custom to place the blame for many skin 
lesions at the door of the digestive canal and in some instances 
rightly, though often without adequate scientific basis of 
fact, to be sure, and only on the strength of clinical evidence. 
There is therefore a vast field as yet inadequately explored, 
and until painstaking nutritional studies are made on more 
diseases, we can for the most part only prescribe diets on the 
basis of bedside experience. The dermatoses due to disturbed 
metabolism may be divided as Johnson^ says into: 

1. Disorders due to derangement of digestion. 

2. Disorders of intermediary nitrogen metabolism. 

3. Disorders due to anaphylaxis. 

The alimentary eruptions von Noorden^ divides into: 

{a) Acute aHmentary erutioons from dietetic causes, such 
as the urticarial erythemata of the vesicular and bullous types, 
which may be produced by strawberries or other fruits, aspara- 
gus, cabbage, fish, cheese, spices and in some even by fresh 
eggs. 

{h) The chronic alimentary eruptions, for example, pellagra, 
ergotism and scurvy, although we believe now that both 
pellagra and scurvy are dependent for their production in some 
way on lack of vitamines. 

Of the disorders of digestion which give rise to eruptions 
we have changes in gastric secretion, notably hyperacidity, 
which give rise to vasoconstriction of the skin vessels, as seen 
in loss of hair.^ 

In disorders of intermediary nitrogen metabolism Johnson 
found that the N partition gave evidence of disturbance shown 

1 Jour. Cut. Dis., 1912, p. 136. 

2 Path, of Metab., vol. iii, 759. 

^ Quart. Jour. Med., 1915, viii, 156. 



PSORIASIS 383 

by a "decrease of urea and a corresponding increase of rest 
nitrogen, and when this was marked, symptoms could be 
looked for." A change in the nitrogen partition occurs in 
eczema, prurigo and dermatitis herpetiformis, particularly in 
the beginning of the attack. It is not at all sure, however, 
that the lack of nitrogen balance is merely a symptom. In 
the class of dermatoses due to anaphylaxis we have a definite 
protein hypersensibility in certain individuals which results 
in such conditions as urticaria and angioneurotic edema. 
These diseases are of course of alimentary origin, as already 
explained, but they may occasionally occur from parenteral 
protein intoxication. 

Tidy, on the other hand, concludes from a study of nitrogen 
metabolism in dermatoses, that: 

1. Changes in the nitrogen excretion in various dermatoses 
are the result of the condition of the skin and are not connected 
with the cause of the disease. 

2. Retention of nitrogen is apparent, not real, and is 
accounted for by the abnormal excretion of nitrogen by the 
skin. 

3. Changes in the nitrogen excretion may precede the erup- 
tion and it is possible that these may survive it. 

In spite of these findings Tidy suggests that a low protein 
diet is worth a trial in dermatoses which are associated with 
disturbances of nitrogen excretion. 

Although authorities differ in their findings, enough has 
been said to show that the storm center is about the metab- 
olism of the protein molecule and that carbohydrate and fat 
enter very little into the discussion of etiology, except in so 
far as they may give rise to some form of gastro-intestinal 
disturbance more from quantity than quality. One notable 
exception to this is, that fat stands in the first place in the 
etiology of eczema, particularly in infants. The relation of 
diet, therefore, to diseases of the skin is undoubtedly, in many 
instances, a most intimate one, but too- little has yet been 
done, with one or two possible exceptions, to place the ques- 
tion on a basis of established fact. 

PSORIASIS. 

This is one disease of which considerable study has been 
made by Shamberg^ and his collaborators, to determine the 
metabolic changes. In their investigations the complement- 
fixation test was not found to be positive, nor was any organ- 

1 Jour. Cut. Dis., October, 1913, p. 708. 



384 DIET IN DISEASES OF THE SKIN 

ism to blame, but a marked nitrogen retention was found 
throughout the period of the experiment and it was felt that a 
definite relationship between the amount of nitrogen in the food 
and the cause of the disease was established. The correspond- 
ing clinical evidence corroborated this, as the patients improved 
on a low protein diet and became worse on a high protein 
allowance; this finding was verified in a number of patients. 
The retention of nitrogen in these cases resembled that seen 
in convalescence and in one instance amounted to 4.89 gm. 
nitrogen per day. Curiously enough, however, these patients 
suffer from what Shamberg calls ^'nitrogen hunger" and patients 
with ''severe psoriasis present a state of remarkable protein 
undernutrition." This is because the retained protein goes 
into making the psoriatic scales which are almost pure pro- 
tein. The success of the low protein diet in these cases is due 
to the fact that we can reach the point in diet at which the 
protein goes only to the vital organs at the expense of the 
scales, so that the latter do not grow. The amount of protein 
is therefore only sufficient to cover the wear and tear of the 
body and leaves nothing over to supply the rapidly growing 
scales. Shamberg ends his conclusions by saying that "the 
low nitrogen diet has a most favorable influence on the erup- 
tion of psoriasis, particularly when it is extensive, almost to 
the point of the disappearance of the eruption." A high pro- 
tein diet, on the other hand, has an unfavorable influence on 
the disease and commonly causes its extension. The practi- 
cal application of these findings in choosing a diet is therefore 
plain; one should keep the protein down to the low level deter- 
mined by Chittenden: 45 to 60 gm. (i| to 2 oz.) of protein 
per day or for a short time on even less, of which the following 
menus are examples: 



Low Protein Diets in Psoriasis. 

Gram?. Ounces 

Bread 245.5 8 

Sugar 63.0 2 

Coffee (breakfast) 210.0 7 

Custard 76.0 2^ 

Milk 250.0 8^ 

Coffee (lunch) 125.0 4 

Potato 1500 5^ 

Lima beans 80.0 2f 

Coffee (dinner) 210.0 7 

Apple dumpling 131 -O 43 

Candy 27.0 

Total nitrogen in food, 8.83 grams --= 55 gm. protein. 

Fuel value of the food, 1929 calories. 



ECZEMA 



385 



Grams. Ounces. 

Bread 164.0 5^ . 

Sugar 89.0 2| 

Coffee (breakfast) 210.0 7 

Sweet potato 1350 #2 

Quince preserve 73-0 2| 

Apple turnovers 118. o 4 

Coffee (lunch) 310 o io| 

Potato 175.0 6 

Peas 80.0 2f 

Apple pie 141. 5 4l 

Coffee (dinner) 210.0 7 

Total nitrogen in food, 7.31 grams = 45 gm. protein. 
Fuel value of the food, 2057 calories. 

Grams. Ounces. 

Bread 221.5 7^ 

Sugar , . . . 77.0 2\ 

Banana 92.5 3 

Coffee (breakfast) 210.0 7 

Baked potato 165.0 5I 

Apple sauce 114.0 4 

Coffee (lunch) 210.0 7 

Succotash 75-0 2\ 

Mashed potato 200.0 6\ 

Chocolate cake 80.0 2| 

Ice-cream 73-0 2\ 

Coffee (dinner) • . . . . 210.0 _ 7 

Total nitrogen in food, 7.63 ounces = 47 grams protein. 

Fuel value of the food, 2065 calories.^ 

Foster's experience, that he could get much more rapid 
results in psoriasis by making the patients vegetarians, is 
easily explained on the basis of facts already submitted. 



ECZEMA. 

This skin disease is of great importance, as it constitutes, 
according to Bulkley, one-third of the entire number of skin 
diseases and its dietetic management is at times exceedingly 
satisfactory. Eczema is caused by a nuipber of different fac- 
tors but in many it can be traced to dietetic faults of (i) to 
eating too much; (2) insufficient food; (3) improper food.^ 

1. In those who eat too much food the cutaneous glands 
are constantly overstimulated, resulting in a change in the 
secretions, and as Thompson says, after long irritation the skin 
finally succumbs to a definite eruption. 

2. When one is run down from insufficient food, skin lesions 
are more apt to develop, particularly since with malnutrition 
from poverty there are usually added unclean personal habits. 



^ Chittenden: Physiological Economy in Nutrition, p. 62. 
2 Thompson: Practical Dietetics, p. 685. 



25 



386 DIET IN DISEASES OF THE SKIN 

3. Everyone knows the effect of improper foods, those rich 
and indigestible, and in persons ingesting such foods eczema 
is prone to develop. 

In adults as well as in children, one or more of these causes 
may be operative, and a careful scrutin}^ of the patient's actual 
dietary is necessary before coming to a definite conclusion as 
to just which causes are at fault in a given case. 

Acute Eczema. — The consensus of opinion is that a limited 
and simple diet is indicated in acute eczema and in fact this 
rule is applicable to all acute inflammatory skin lesions. Such 
a restriction is best accomplished by placing the patients 
either on an exclusive milk diet or with cereals, bread, butter 
and fresh green vegetables or on the so-called rice diet which 
Bulkley recommends from large experience. Bulkley's diet 
consists exclusively of rice, bread and butter and water for at 
least five days, after which other foods are gradually added. 
The rice should be thoroughly cooked for from thirty to sixty 
minutes in water, not with milk. It can be dried out a little 
after cooking if it is more palatable in this form. Butter and 
salt are to be eaten on the rice, which should be taken very 
slowly, accompanied by thorough mastication. The bread 
should be stale. According to Bulkley the rationale of this 
diet lies in the fact that acute eczematous manifestations are 
due to retained nitrogen waste products, and giving a diet 
that is almost nitrogen-free allows the kidneys to excrete the 
retained matter, and when this is accomplished the acute 
stage of the eruption comes to an end. 

At the end of five days it is advised to return gradually to 
a mixed diet, taking first one regular mixed meal at midday 
and the rice diet morning and night. 

If this is successful a light breakfast is given, such as cereal 
with butter, eggs and bacon and possibly a little weak tea or 
coffee, 1 soft green vegetables, farinaceous puddings, whole 
meal bread, eggs, milk, chicken, fresh fish are then added. 
Many authorities forbid fruit in any form while others allow 
it stewed without sugar and still others fresh, if ripened nearby 
and not picked green. 

Chronic Eczema. — In chronic eczema the question as to 
**too much," **too little" or ''improper food," comes up, in a 
way, for consideration much more than in the acute form. 
Here much can be done to bring about a favorable progress 
of the disease by cutting down the food of the glutton, feeding 
up the poorly nourished and regulating the diet of those who 
habitually eat indigestible or improper foods. 

^ Bulkley: Diet and Hygiene in Diseases of the Skin, p. 70. 



ECZEMA 387 

Among articles of food that should not be touched by these 
patients are spices, condiments, alcohol, fried foods, rich 
gravies, pastry, sweets, cake, cheese, salt food, ham, nuts, 
corned beef, salt pork, much meat and meat soups, salads and 
twice-cooked meats and curries. 

The low (Chittenden) level of protein is advisable for those 
who habitually overeat. These prohibitions also hold for the 
** after-diet" in acute cases. 

Eczema in Nurslings. — Here the dietetic and hygienic faults 
are the mother's, and attention to her intake, exercise, and 
bathing, will often result in the relief of the infant's eczema. 
There are commonly two varieties seen: 

1. In overnourished, fat babies who have shown evidence 
of eczema since birth. 

2. In those babies who have previously thriven, but who 
develop gastro-intestinal trouble and eczema, seen espe- 
cially when they are weaned and put on an improper rhilk 
mixture. 

In the first group the mothers are usually found to overeat 
or take too much alcohol and too little exercise. In the second 
group the babies' stools indicate indigestion, which, if rectified 
results in a cure of the eczema. Finckelstein has obtained 
good results by feeding nutrose (casein preparation) before 
each feeding or by giving buttermilk twice a day with some 
additional carbohydrate.^ In artificially fed children with 
eczema Holt advises giving food moderately high in fat and 
low in protein and if not successful he reduces both fat and 
protein. In some instances, according to C. M. Williams, it is 
advisable to withdraw milk entirely from the diet and substi- 
tute wheat jelly, thin gruels, beef juice and eggs. Also careful 
attention must be given to the regulation of the times of 
feeding. Still other children are benefited as soon as they can 
be placed on mixed feedings, this is particularly true in the 
chronic form. It is also true here, as in adults, that those 
children who are overfed will do better' if the food is reduced 
both in quantity and quality and, vice versa, the undernour- 
ished fed more liberally. 

Meyer found that children with chronic eczema showed salt 
retention which in turn leads to water retention predisposing 
to eczema. On this basis Finckelstein fed a salt-free milk 
diet with high protein and carbohydrate with good results. 

This salt-free milk is prepared by removing the salts by 
washing the casein in water then mixing the curd with four- 
fifths water and one-fifth whey with the addition of 40 to 50 

^ Lyman: Arch, Ped., 1915, xxxii, 175, 



388 DIET IN DISEASES OF THE SKIN 

gm. of salt-free carbohydrate. This is known as "eczema 
soup." 

This is not appHcable to all cases, but does best in fat babies 
with a moist, "weeping," impetiginous eczema, when protein 
digestion is poor, as shown by curds and undigested stools. 

Reducing the percentage of the protein in the food will 
often result in clearing up the eczema. ^ 

Since there is apt to be a very high urinary acidity in all 
chronic cases of eczema this should be rectified by giving large 
amounts of water plain or alkaline. 

The dietary regulations given are good so far as they go 
and in some instances are sufficient for a cure, but almost 
all cases require local treatment as well. 

ACNE ROSACEA. 

The underlying condition in acne rosacea is a vasomotor 
instability affecting particularly the blood supply of the skin 
of the nose and cheeks, resulting in abnormal flushing of these 
parts of the face.^ Such a condition can be brought about 
temporarily, even in normal persons, by hot drinks as soups, 
tea, etc., particularly in an overheated room. Alcohol is of 
course the greatest etiological factor in the production of 
chronic rosacea, although it by no means follows that all 
chronic cases can be traced to this as a cause. The alcohol 
acts largely through the gastritis which it causes; gastric 
hyperacidity from other causes being also frequently respon- 
sible for the production of acne rosacea. Chronic indigestion, 
gastric or intestinal, associated with the putrefaction of animal 
protein and often accompanied by high percentage of indican 
in the urine, acts much in the same way and must be kept in 
mind when prescribing a diet. 

The proper diet in rosacea is one from which are excluded 
all the known etiological factors, e. ^., alcohol, hot tea, coffee, 
soup, spices, condiments, fried food, rich sauces, gravies, 
made-over dishes, pastry, heavy sweets, rich cake, and 
everything known by the individual to be a possible cause of 
gastro-intestinal indigestion. Patients should themselves 
notice the effects on the skin of any particular kind of food 
and learn to avoid those things which cause flushing. Of the 
greatest importance is the patient's general hygiene — baths, 
exercise, fresh air and water drinking — all of which is equally 
true in both acne rosacea and acne vulgaris. 

^ Lyman: loc. cit, 

2 Q^ 'f^ Jackson: Diseases of the Skin. 



ERYTHEMA 389 



ACNE VULGARIS. 



In acne vulgaris the ducts of the sebaceous glands become 
closed, the plugs consisting almost entirely of epithelial cells 
with practically no foreign substances in them. A secondary 
staphylococcus infection is then engrafted on this, as the 
opsonic index is low to the staphylococcus, and results in 
pustulation or at least deep skin infection which may be only 
inflammatory, short of the production of pus. One factor 
which probably favors the infectious element is the fact that 
in acne vulgaris the percentage of blood sugar is higher than 
normal. This form of acne is most frequently seen in young 
people at puberty and often disappears after a few years, 
although in some cases it is ofexceedingly prolonged duration 
and taxes the ingenuity of the dermatologist. 

Where the patients are found to be excessive eaters, the 
quantity of food should be cut down and will often give relief — 
in some cases Jackson obtains the best results on an exclusive 
milk diet. On the other hand, when the acne is an accompani- 
ment of malnutrition the patients should be liberally fed and 
everything done to improve their general health with conse- 
quent raising of their opsonic index. Tea, coffee and alcohol 
and all indigestible foods are forbidden. The amount of fat 
food should be limited and much the same restrictions insisted 
upon as indicated for acne rosacea. Williams^ bars cheese, 
pickled food, sausage, cabbage, cauliflower, griddle cakes, oat- 
meal and pastries, fresh bread and salads. Sweets are espe- 
cially to be forbidden as favoring a still further increase in the 
percentage of blood sugar. 

ERYTHEMA. 

Erythema occurs in so many forms; simple erythema, 
erythema nodosum, multiforme, urticarial and hemorrhagic 
erythema — all of which are undoubtedly varying skin reac- 
tions to a variety of toxic ingesta, and it is difficult to know 
just where to begin a discussion of the subject from a dietetic 
point of view. Many persons learn early in life what foods 
will produce these eff"ects and avoid them; again persons seem 
susceptible at one time to a certain food and not at another, 
so that to know just which form of food is responsible for a 
particular attack, often presents a problem of some difl&culty. 
Where erythema multiforme is seen with urticaria it is prob- 
ably of gastro-intestinal origin; if with purpura it is more apt 

^ Williams: Food and Diet, p. 337. 



390 DIET IN DISEASES OF THE SKIN 

to be due to some focus of infection or from a ptomaine tox- 
emia.^ Of course, it goes without saying that where a cer- 
tain form of food is at fault that food should be avoided in 
future and the best method of treatment in addition to this 
advice is an initial thorough emptying of the digestive canal 
combined with the simplest sort of diet possible, in order to 
keep down intestinal putrefaction with its accompanying 
by-products which are most often at fault. To this end a 
lactovegetarian and farinaceous diet is best and is usually 
promptly efficient in the transient forms, such as in acute 
urticaria so often caused by fish or shell fish. In the more 
prolonged types, such as erythema multiforme, it is often 
necessar}^ to continue such a diet or at least a very bland and 
unirritating diet for a considerable length of time or until the 
eruption is entirely cleared up. 

In chronic urticaria we have a difficult problem and from 
a dietetic point of view an almost hopeless one unless we are 
fortunate enough by a process of exclusion to find some par- 
ticular food which is at fault. Often, however, this is impos- 
sible and the most one can do in diet is to give simple and easily 
digested foods which, at least, will not increase the trouble by 
adding an intestinal indigestion. Since urticaria is thought 
by some to be always an anaphylactic phenomenon, the die- 
tetic suggestions detailed under Asthma may prove most help- 
ful in arriving at a proper dietary regimen. (See p. 285.) 

Erythema accompanying infection cannot, except second- 
arily, be influenced by diet, but at least nothing should be 
given to increase the skin irritation and avoidance of the class 
of so-called food irritants, such as condiments, spices, garlic, 
and alcohol, should be insisted upon. 

PRURITUS. 

Pruritus in any of its forms is an itching condition and may 
be due to many causes, ranging from an inherited irritable 
skin to that due to overassociated hemorrhoids or fissure, 
tobacco in excess, renal poisoning, diabetes, cold, ascarides, 
etc. 2 Most of these conditions, it will be readily seen, are 
not amenable to dietetic relief and yet we can do much to add 
to the discomfort of an already irritable skin by an improper 
diet. 

When the itching is intense and the skin at all generally hot 
and inflamed it is a good plan to put the patients on a very 
bland lactovegetarian diet for a few days, as is true of all acute 

1 Anthony: Jour. Cut. Diseases, 1912, p. 112. 

2 Jackson: Disease of the Skin, p. 450. 



DERMATITIS 391 

inflammatory skin lesions. Later avoidance of the stimulating 
class of foods such as condiments, is indicated; Jackson espe- 
cially interdicts the use of alcohol, tea, coffee and tobacco; 
some of the worst cases are seen in heavy smokers, and the 
condition is distinctly aggravated by even moderate smoking. 

"Prurigo and lichen urticatus are closely related to urticaria 
and are accompanied by a highly susceptible vasomotor or 
sensory nerve system set in action by a variety of excitants 
which often elude one's investigation."^ 

In these conditions the diets suggested for rosacea and 
urticaria are useful. 

DERMATITIS. 

Dermatitis Herpetiformis. — Hardouin found retention of 
urea in the system just before the eruption in 8 cases, so 
that this is undoubtedly the local manifestation of a general 
metabohc disturbance and as retention of purine bodies prob- 
ably lies in a causal relation to the disease it would be appro- 
priate to prescribe a diet similar to that advised in gout or at 
least a very low purine diet, accompanied by effectual elimina- 
tion through all the exits. Other investigators found normal 
urninary excretion and cultures and experimental inoculations 
of the liquid from the bullae negative, and think much points 
to a deranged nervous system as the cause of dermatitis 
herpetiformis. During the acute stage the diet should be 
simply milk; tea, coffee and alcohol are forbidden — ^when the 
inflammatory condition has subsided, vegetables, farinaceous 
foods and eggs may be added to the diet, returning gradu- 
ally to a normal diet, excluding indigestible and purine-rich 
foods. (See Diet in Gout.) 

Exfoliative Dermatitis.— Probably the best results are 
obtained with a milk diet and in addition the use of colonic 
irrigations. Jackson (G. T.) advises flaxseed tea several times 
a day. After the acute stage is over a diet as in eczema is 
valuable. 2 

Ferunculosis. — Ferunculosis should be treated dietetically 
like acne vulgaris and the same rules hold good. As it is 
especially prone to develop following severe illness during the 
period of convalescence, the indications are usually for a full 
nourishing diet, but simple withal. 

Comedones. — Comedones are due to the blocking of the 
sebaceous gland ducts by a disordered secretion and are often 
accompanied by gastro-intestinal disturbances. The diet should 
conform to the actual digestive disorders present in an individual 

^ Sutherland's Dietetics. 

2 Thompson: Practical Dietetics, p. 685. 



392 DIET IN DISEASES OF THE SKIN 

case and besides careful hygiene of the skin, ehmination should 
be increased by copious water drinking. 

Hyperidrosis. — Since the sweating which accompanies hyper- 
idrosis is caused by a vasomotor disturbance, general hygiene 
plays a part in the cure, with which must be included of 
course, diet, and although there is no specific diet that is indi- 
cated, patients with hyperidrosis should avoid digestive risks 
and generally keep to simples in diet. When the hyperidrosis 
is accompanied by obesity, uricacidemia or some nervous con- 
dition, these should receive their appropriate hygienic and 
dietetic treatment. 



CHAPTER XXIV. 
DISEASES OF THE GENITO-URINARY SYSTEM. 

NEPHRITIS. 

In attempting to discuss the food factor in nephritis, it 
must be kept in mind that the relation of diet to nephritis is 
twofold — (i) in its causation role, about which we know little; 
(2) in its relation to rational treatment and dietetics of the 
disease, about which we know more but still too little. That 
food does often stand in an important role as the causation 
of nephritis must be admitted, although as yet we have but a 
glimmering of its true significance — but when we stop to think 
of the known drugs and foods which directly irritate the epi- 
thelium in greater or less degree, such as cantharides, turpen- 
tine, lead, arsenic, salicylic acid, mustard, peppers, the oil 
from garlic, onion and celery and numerous other substances — 
it is but a short cry to the possibility of repeated minimal 
irritation by foods less well recognized as renal irritants. The 
analogy of liver cirrhosis is sufficient for purposes of compari- 
son, and while the liver is damaged in the attempt it makes 
to detoxify the irritating alcohol, hot sauces, etc., the kidney 
must run an equal risk in its excretion of most of the products 
of protein metabolism. That this is so has been increasingly 
evident and we have come to recognize still another form of 
renal irritant in re-peated anaphylactic shocks as demonstrated 
by Longcope by the injection into animals of protein after 
previous sensitization to these same proteins. After a large 
secondary dose of protein, acute degeneration of the renal 
epithelium is seen, or if less acute, one finds collections of 
round cells about the vessels and in the intermediate zone. 
If the process is long continued there is found a connective- 
tissue increase and glomerular lesions. These changes are 
not confined to the kidney but are seen in the parenchyma of 
other organs. It can therefore be seen that a patient may 
unconsciously be constantly receiving mild, unfelt anaphy- 
lactic shocks from certain food proteins to which he is sensi- 
tive, with resulting renal changes. Again, any food that has a 
tendency to produce acid or to lower the alkaline reserve of 
the blood, will result in damage to the kidney. Among such 
food may be mentioned excessive protein or fats, also inorganic 
acids. 



394 DISEASES OF THE GEN I TO-URINARY SYSTEM 

So presumably anything that reduces the alkaHne reserve 
causes a damage to the cell protoplasm, which if constantly 
repeated may well result in nephritis. Besides the lessened 
alkalinity of the blood, Auld suggests demineralization (cal- 
cium loss) and impaired metabolism as results of an acid 
excess. 

Gross overeating is undoubtedly a cause of kidney change 
probably of a fibroid nature, as we know that the same cause 
acts in producing arteriosclerosis, in which process the kidney 
shares, as do other organs. Taken then all together, there are 
definite ways in which food may act in the production of renal 
changes, although it is often a matter of great difficulty to 
decide in a given case just which cause is primarily at work, 
after the exclusion of the more usual causes of renal irritation, 
such as the infectious diseases, intestinal toxemia, etc. 

The newer studies in kidney functions have brought to light 
many facts which have helped us to inderstand findings which 
were for so long obscure. Unfortunately they have not yet 
gone so far that we can classify all cases of nephritis, acute 
and chronic, to our entire satisfaction, but enough has been 
accomplished by experimentation to justify certain therapeutic 
conclusions that have proven of great value. 

The factors which must be taken into especial consideration 
in dealing with the dietetics of nephritis have to do with the 
excretion of various substances derived from the digestion of 
foods, and the different behavior of the diseased kidney from 
the normal kidney with respect to their elimination. One 
starts with the premise that the healthy kidney can perfectly 
eliminate water, nitrogenous products of protein combustion, 
certain inorganic salts, notably sodium chloride, and organic 
compounds, which result from bacterial activity. When one 
then begins to classify the cases of nephritis with respect to 
the individual's power to excrete these substances, one soon 
finds that they are almost never found to be of one simple 
type, but, since the structures of the kidney are all more or 
less involved, the excretion of one, two or all classes of con- 
stituents of normal urine may be interfered with, so that the 
kidney's behavior to the excretion of these various substances 
is not absolutely fixed. In spite of this fact, most of the cases 
may be grouped separately according as the excretion of one 
or another urinary constituent is chiefly interfered with. 
With experimental nephritis it is somewhat different; we can 
by means of various kidney poisons, artificially introduced 
into the animal's body, produce what is practically a pure 
type of tubular, glomerular or interstitial nephritis, and it 
has been by watching the elimination of the normal urinary 



NEPHRITIS 395 

constituents under one or another form of artificially produced 
nephritis that we know as much as we do in regard to the 
behavior of the kidney toward the normal urinary constituents 
with respect to their elimination. 

For a full discussion of the various diagnostic methods to 
determine the renal function founded upon the results of 
experimental nephritis, such as the sulphophenolpthalein test, 
salt test, potassium iodide test, lactose test, the determination 
of the Ambard coefficient, water test and diet test days, the 
reader must be referred to any one of the newer editions of 
standard text-books on internal medicine. In order to know 
just which type of renal hypofunction a given case belongs to, 
some of these tests must be made and together with the his- 
tory and clinical findings a fairly accurate idea can be obtained 
as to which function or functions of the kidney are disturbed 
and the diet arranged accordingly. 

Kidney Dietary Tests. — ^Water Excretion. — It is a simple 
matter to determine the water excretion by ordering a definite 
amount of water for the twenty-four hours and measuring the 
actual fluid intake and urinary output; thus if 1500 c.c. (50 oz.) 
are taken and 1200 c.c. (40 oz.) or thereabout represents the 
output for twenty-four hours, the water excretion is consid- 
ered normal under ordinary conditions of temperature and 
humidity, as the 300 c.c. (10 oz.) discrepancy between intake 
and output is lost by bowel, skin and lungs. 

Salt Excretion. — ^This is determined by noting the daily salt 
output both as to concentration (percentage of NaCl in the 
urine) and the total twenty-four-hour output on a known salt 
intake. For this purpose one of the salt-poor diets are used 
with a known salt content, to which a definite amount of salt 
is added after weighing. This should be done for several days 
and accurate daily estimations made. Normally the kidney 
should be able to concentrate chlorides up to 0.6 to 0.9 per 
cent, with a total daily excretion of practically the entire 
intake.^ 

Nitrogen. — The determination of nitrogen excretion is some- 
what more difficult, but it can be done if the patient is placed 
upon a fixed nitrogen diet and the daily nitrogen balance 
determined. For this a well-equipped laboratory is neces- 
sary, while for the determination of water and salt excretion 
very little is needed in the way of apparatus. Schlayer's 

^ Test for the Amount of Salt in the Urine. — Dilute 10 c.c. of urine with 900 c.c. 
of water and add one or two drops of 25 per cent, nitric acid. This mixture 
should be made alkaline with a 10 per cent, solution of sodium carbonate adding 
a few drops of a 10 per cent, potassium chromate for an indicator. Titrate with j^ 
normal silver chloride solution. Every c.c. of silver solution used equals 0.00583 
gm. of sodium chloride. 



396 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

nephritis test day, as modified by Mosenthal, gives the informa- 
tion desired in the matter of water, sodium chloride and nitro- 
gen excretion in the most convenient way as follows: 

Directions for Schlayer's Nephritic Test Day 
(Mosenthal). 

Needed in the ward. 

7 wide-necked bottles, each labelled. 

I bottle to hold looo c.c. for night specimen. 

6 bottles to hold 500 c.c. each, for two-hour specimens 

during day. 
Salt in capsules, each capsule to contain 2.3 grams sodium 
chloride. 
Preceding day's diet should be *'soft salt-free" with fluids 
limited to 1500 c.c. 

Test Day. — All food is to be salt-free, from diet kitchen. 
Salt for each meal will be furnished in weighed amounts 
(one capsule containing 2.3 grams, sodium chloride with each 
meal). 

All food or fluid not taken must be weighed or measured 
after meals and charted. 

Allow no food or fluid of any kind except at meal times as 
directed. 

Note any mishap or irregularities that occur in giving the 
diet or in collection of specimens. 

Meals to be given at the following hours: 
Breakfast, 7.45 a.m. 
Dinner, 1145 a.m. 
Supper, 4.45 P.M. 
No fluids between meals or during the night. 
Collection of urine during the day every two hours, and 
from 7.45 P.M. to 7.45 A.M. 

Empty bladder at the following times: 
No. of specimen: 7.45 a.m. discard 

1 9.45 A.M. save in separate bottle 

2 11.45 A.M. " " 



3 


1.45 P.M. 


4 


345 P-M. 


5 


545 P-M. 


6 


7.45 P.M. 


7 


7.45 P.M. to 7.45 A. M 



Label each bottle with period of collection, number of speci- 
men and name of patient and send to laborator3^ 
Breakfast, 7.45 a.m. — Chart food or fluid not taken. 

Boiled oatmeal, 100 grams; sugar, one-half teaspoonful; 



NEPHRITIS 



397 



Milk, 30 C.C.; 

Two slices of bread (30 grams each); butter, 20 grams; 

Coffee, 160 C.C.; milk, 40 c.c; sugar, one teaspoonful; 

Milk, 200 c.c; 

Water, 200 c.c. 
Dinner, 11.45 A-^- — 

Meat soup, 180 c.c; 

Beefsteak, 100 grams; 

Potatoes (baked, mashed or boiled), 130 grams; 

Green vegetables as desired; 

Two slices bread (30 grams each); butter, 20 grams; 

Tea, 180 c.c; milk, 20 c.c; sugar, one teaspoonful; 

Water, 250 c.c; 

Pudding (tapioca or rice), no grams. 
Supper, 4.45 P.M. — 

Two eggs (cooked in any style) ; 

Two slices of bread (30 grams each); butter, 20 grams; 

Tea, 180 c.c; milk, 20 c.c; sugar, one teaspoonful; 

Fruit, stewed or fresh, one portion. 
One capsule of salt with each meal = 3 x 2.3 grams. 

Findings in a Case of Chronic Hypertensive Nephritis. 



Time. 


Amount 
c.c. 


Sp. gr. 


Sodiurr 
Per ct. 


chloride. 
Total. 


Ni 
Per ct. 


trogen. 
Total. 


Approximate intake. 


745 to 945 
945 to 1 1 45 
II 45 to 145 
145 to 345 
345 to 545 
545 to 745 


155 

97 
98 

255 

43 

325 


IOI3 
lOII 
IOI4 
lOIO 
IOI5 
lOII 






•• 




Fluids 1760 C.C. 

Salt 8.5 gms. 
Nitrogen 13.4 " 


Total day 
Night 


983 
800 


.... 
IOI4 


.16 
•215 


1-57 
1.72 


•37 

.48 


363 
3-85 




Total 24 hours 
Intake 


1783 
1760 


.... 

.... 




3-29 

8.5 




749 

134 




Balance 


-23 






+ 5-21 




+591 





The figures show a negative water balance, but retention of both chlorides and 
nitrogen. 



In discussing the various urinary elements and their excre- 
tion, from the clinical point of view, we have a number of 
questions to be kept in mind. 

Water. — It was long thought that the giving of large amounts 
of water in any form of nephritis was the best thing one could 
do for the patient, with the idea of washing out the poi- 
sonous products of incomplete or even complete metabolism, 



398 DISEASES OF THE GEN I TO-URINARY SYSTEM 

Von Noorden differed from this view and showed that in 
certain cases the kidney could not ehminate water as well as 
it could other substances and the only effect of giving it in 
large amounts was to increase the edema, or if there was no 
edema, to overfill the circulatory apparatus, putting an extra 
strain on the heart and bloodvessels. 

In the normal individual there is a loss of water through 
skin and pulmonary excretion of approximately one-fifth of 
the intake, so that if a patient is given 2000 c.c. (66 oz.) of 
fluid, i. e.y 1500 c.c. (50 oz.) as fluid direct and about 500 to 
750 c.c. (16-25 oz.) in the food taken (which Mohr calculates 
to be about the amount of fluid contained in the ordinary 
diet) only 1600 to 1700 c.c. or thereabout will be excreted by 
the kidney (53 to 56 oz.) and the rest is lost in the ways already 
referred to. When in nephritis the amount excreted is still 
markedly less, then one may be sure that he is dealing with 
a nephritis which finds difficulty in eliminating water, the 
unexcreted balance being held in the serous cavities, subcu- 
taneous tissues or circulation. The question may well be 
asked, What then is the optimum amount of water to give in 
nephritis.^ To this no hard-and-fast rule can of course be 
given, but Mohr^ found by experimentation that "in any 
form of nephritis the maximum amount of solids were elimi- 
nated if the patient passed from 1250 to 1500 c.c. (42 to 50 oz.) 
of urine." Miller^ further states that when the kidney is able 
to excrete the normal amount of fluid and there is no evidence 
of edema, 1500 to 2000 c.c. (50 to 66 oz.) of fluid is quite 
enough to give in twenty-four hours. When there is diffi- 
culty in water excretion then the total amount of water best 
to give must be determined in accordance with that particular 
patient's capability as determined by daily measuring the 
intake and the urine, the doing of which is only a detail of 
general management. 

Salt.^ln the consideration of the salt excretion, two classes 
of salts are to be considered; the chlorides, of which sodium 
chloride is the most important example, and the sulphates 
and phosphates, both of which latter behave much as the 
nitrogenous products do and not as the chlorides. If the 
patients have no subcutaneous edema the chloride elimination 
is normal even if the nitrogen elimination is poor. In other 
words, nephritis with edema invariably shows salt retention.^ 

Strauss puts the principles involved thus: *'The human 



1 Bcitragc Zur Diatctik dcr Nicrenkrank. Ztschr. fur klin. Med,, 1903, p. I377- 

2 Forchhcimcr's Therapeutics, vol. iv, 34. 
^ Ibid., vol. iv, 22. 



NEPHRITIS 399 

organism holds fast with extreme tenacity to the percentage 
concentration of the fluids in sodium chloride." This is done 
by a regulating mechanism of which the kidney stands in the 
first rank. When more than enough salt is taken by a healthy 
person it is promptly eliminated and when the organism is 
starved, as in extreme vomiting, the output of salt in the 
urine is at once diminished in order to keep the blood concen- 
tration at about 0.6 to 0.9 per cent.^ Strauss also reached the 
conclusion that the chloride retention in nephritis with edema 
was of renal origin and that withdrawal of salt from the diet 
(all but the necessary 1.5 or 2 gm. per day) was necessary for 
treatment. The three factors on which he based his views 
were: (i) that in unilateral nephritis lower chloride value 
are found in the urine from the diseased kidney; (2) in an 
exacerbation of the disease the value of sodium chloride 
excreted often falls off; (3) that dropsies were helped by 
remedies which caused not only an increased water output 
but at the same time a polychloruria. Dechlorination accord- 
ing to the same authority consists of two elements: (i) a 
salt-poor diet; (2) salt elimination from medicaments. 

The minimum of salt which is necessary to maintain the 
normal molecular salt concentration, as already stated, is 
about 1.5 gm. per day, but as it is almost impossible to con- 
struct a salt-poor diet with less than this amount, there is no 
practical danger of actual salt starvation, provided there are 
enough calories in it to meet nutritional demands. 

Nitrogen. — When we turn to nitrogen elimination we find 
that in the mild types of nephritis the nitrogen elimination is 
delayed as compared with the normal person. This delay 
being caused (judging by experimental nephritis) by injury to 
the glomeruli. 2 When one has to do with a more severe 
nephritis it is found that the nitrogen compounds are retained 
in the blood and tissues. These facts are of paramount impor- 
tance in prescribing definite amounts of protein food, for with 
the more severe cases accompanied by nitrogen retention we 
must reduce the protein intake not only to the nutritional 
minimum but below this for a short time. 

GoodalP discovered that by placing chronic nephritics on a 
low protein diet the blood-pressure fell and on examining the 
blood of these cases that had been so dieted he found the non- 
protein nitrogen lowest and he therefore concludes that the 
general condition and blood-pressure were improved when the 



^ Strauss: Post Graduate, 1913, xxviii, 532, 
2 Manakow: Deutsch. klin. Med., April, 191 1. 
^ Boston Med. and Surg. Jour., 1913, clxviii, 761. 



400 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

end-products of protein metabolism in the blood were lowest. 
Frothingham and Smillie^ tried diets in chronic nephritis of 
low, medium and high protein content and concluded *'that 
in certain types of chronic nephritis the nitrogenous content 
of the diet should be carefully watched in order to prevent an 
increase in non-protein nitrogen in the blood. The exact 
effect of an increase in blood nitrogen produced by a high 
nitrogenous diet is not known at present, but presumably it 
is unfavorable to the best interests of the patient, since in some 
it increases their discomfort. A diet low in nitrogen content 
will frequently keep down to normal the non-protein nitro- 
gen of the blood in chronic nephritis. In uremia the non- 
protein nitrogen is always high." To this last statement there 
are known exceptions. 

While the foregoing facts represent the general opinion in 
regard to kidney function and the influence of the various 
food-stufFs in the matter of excretion, another school of clini- 
cians, of whom Martin Fischer is perhaps the best known, take 
exception to almost all of these ideas and contradict flatly 
many of the foregoing statements, in fact, most of them; thus 
for example Fischer recommends in all cases of nephritis that 
large amounts of water should be given even if apparently 
the patient is not excreting the normal proportion of the fluid 
intake. This is done to dilute the body acids so that they can 
be excreted, for "a kidney that is killing itself clearly needs 
water to rid itself of the poisons that are killing it."^ Too 
much water he admits sometimes increases the swelling of the 
kidney and washes out valuable salts, but these objections 
are overcome by giving certain salts with the water, notably 
sodium chloride and sodium carbonate.^ 

If ordinary dried sodium carbonate is obtamable only one- 
third as much as the crystallized should be used. 

In regard to the use of the salt-poor diets Fischer and his 
school, as championed by Lowenburg^ feel that the salt-poor 
diet may lead to albuminuria and nephritis which Fischer 
explains as being *'due to the low salt content of the body 
occurring as a result of food without salt," which as already 
stated he believes washes out the salts naturally present. This 
salt starvation leads to renal acidosis and this to nephritis as 
represented by albuminuria, cloudy swelling, casts and edema. ^ 

^ Arch. Int. Med., 1914, xv, No. 2, 225. 

2 Martin Fischer: Nephritis, Cartwright Prize Essay, 191 1. 

3 The solution Fischer uses is: 

vSodium carbonate (crystallized) . 20 gm. f f oz. "l 

Sodium chloride 14 gm. i \ oz. \ given by rectum. 

Water q. s. ad 1000 c.c. [ quart j 

* Jour, Am. Med. Assn., November 28, 1914, p. 1906, ^ Loc. cit. 



NEPHRITIS 401 

Lowenburg's conclusions in regard to NaCl based on Fischer's 
teachings are: 

1. Sodium chloride neither produces nor increases water 
retention in nephritics and non-nephritics. 

2. It is curative in cases of edema from any cause provided 
the kidneys are not too much damaged. 

3. When combined with alkahs and plenty of water it 
exerts a beneficial effect on the symptoms of nephritis. 

4. The best method of giving the salt is in an alkahne solu- 
tion by rectum or intravenously (not hypodermically). 

The answer to Fischer's objection, that a salt-poor diet 
causes sodium chloride starvation and low salt content in the 
body, is, that first, in severe nephritis the salt concentration in 
the blood is above normal and second that it is practically 
impossible as already explained, to give a salt-poor diet which 
contains less than i or 1.5 gm. sodium chloride, sufficient for 
the body needs for a considerable time, and at best a salt-poor 
diet of the lowest salt content is only a temporary expedient 
and a matter usually of not over ten to fourteen days. 

In dealing with the actual diets recommended for the various 
types of nephritis and their complications, the classification of 
renal diseases must necessarily be a simple one and a division 
into acute and chronic nephritis with or without nitrogen, 
salt, or water retention, one or more in combination, is about 
as far as we can go at present. The older method of ordering 
diet merely upon the basis of the supposed pathological changes 
in the kidney is no longer useful in the light of our present 
knowledge of renal function. 

Albuminuria. — Albuminuria being a symptom of renal irritation 
may be produced in a great variety of ways. It may be toxic 
in origin from chemical irritants that may have been ingested, 
e. g., turpentine, cantharides, mercury, etc., or from the toxemia 
arising from bacterial infection in the course of any of the 
acute or chronic infections, or as an early manifestation of 
primary renal disease or finally as a part of a general asthenia 
characterized by visceroptosis, small heart and ordinarily 
designated as an orthostatic albuminuria. 

When the albumin in the urine is a symptom of actual renal 
irritation, chemical or bacterial, it is necessary to treat the 
causal conditions by removal of poisonous materials from the 
food and to furnish such a dietary that no unnecessary strain 
shall be put upon the renal epithelium. For this purpose a 
milk or lactofarinaceous diet is best, milk alone being used 
for the more serious cases and farinaceous additions being 
made in the milder grades. When the albuminuria is a part 
of a general acute or chronic infection, the diet must conform 
26 



402 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

largely to the requirements of the particular infection at fault, 
but in general the milk or lactofarinaceous diet fills the 
requirements perfectly and must be kept up as long as the 
signs of renal irritation persist. 

Where there are difficulties in the excretion of water, salts 
or nitrogen, as shown by edema or any evidences of acute 
uremia, it is often best to use either the Karell diet or one of 
the soft salt-poor diets, or with impending uremia a day or 
two of starvation, giving only water combined with hot packs, 
and colon irrigations, to relieve the internal congestion. 

In the ordinary milk diet, when that is applicable to these 
cases, we may order from 1500 to 2500 c.c. (3 to 5 pints) of 
milk per day given in 180 to 240 c.c. (6 to 8 ounces) dosage, 
every two hours. 

As the albuminuria and other evidences of any inflammatory 
reaction subside and remain in abeyance, other articles of diet 
may be added — all farinaceous foods, vegetables, except those 
which contain irritating oils such as onion, garhc and celery; 
and lastly when things have settled back to what is practically 
a normal condition, a small amount of meat may be allowed. 

In the case of orthostatic albuminuria it is not necessary to 
diet strictly, for it has practically no effect on the quantity of 
albumin in the urine, all that can be done is to avoid an excess 
of any food or drink, particularly meat products and alcoholic 
beverages. 

Acute Nephritis. — In cases of acute nephritis from whatever 
cause (except mercury poisoning, q. v,) the diet must be 
exceedingly sparing, and it is often best in acute uremia, pro- 
vided there is no water retention, to give nothing but water 
for twenty-four hours in rather considerable amounts, reliev- 
ing the kidney from the necessity of excreting nitrogen except 
that of enodgenous origin. In these cases water excretion is 
often low, not so much as a result of any impermeability of 
the kidney to water as from conditions arising in any disease 
accompanied by fever, which is usually present in acute cases. 
The various methods to get water into and out of the system 
are advisable in certain cases, such as water by mouth, hot 
colon irrigations, hypodermoclysis, saline infusion (in very 
severe cases), hot packs and catharsis. All these methods 
both spare the kidneys and at the same time act favorabh^ by 
flushing them out; just which methods shall be used must 
depend on the severity of the case. In the less serious cases 
and on the second day in serious cases, feedings may be begun; 
Tyson^ recommends 2 ounces of milk every two hours for 

1 New York Med. Jour Tanuary 31, 1914, p. 223. 



NEPHRITIS 403 

a few days. This is of course a modified form of the Karell 
diet which will be described under chronic nephritis. The 
quantity of milk can be increased as the urine secretion rises 
and to it may be added within several days farinaceous 
articles of diet, especially bread, cereals and barley gruel, all 
served with a moderate amount of sugar. Nothnagel recom- 
mends adding fats, as butter and cream, then light green vege- 
tables; these latter according to most American usage are 
chosen chiefly from those varieties which grow above 
ground. 

Practically all authorities agree that a prolonged and exclu- 
sive milk diet is distinctly a bad thing, as it results in anorexia, 
coated tongue and often in intestinal indigestion with diarrhea. 
There is no doubt, however, that milk should form the bulk of 
the diet in the acute cases, although it is well not to give a 
daily total of protein over 30 to 40 gm. at first, gradually 
increasing this perhaps to 70 to 80 gm., depending on excre- 
tion and the size of the patient. This lactofarinaceous- 
vegetarian diet fills the requirements of food value, variety 
and bulk, with the minimum of renal irritation. The appetite 
can usually be trusted to take approximately sufficient food 
with the restrictions exercised particularly in the protein 
foods as indicated, and although the total caloric value of the 
food will necessarily be low at first, it is better so, and as the 
appetite returns the quantity may be increased at will. 
Fischer's explanation of the benefit from a lactovegetarian 
diet is that it contains much fluid and that the salts in the 
vegetable fruits produce carbonates in the blood which in 
turn counteract renal acidosis. He also explains in the same 
manner the usefulness of the old empirical alkaline mixtures 
given for nephritis, such as the potash salts. 

If these cases are prolonged and become subacute, develop- 
ing edema and difficulty with salt and water excretion, they 
had best be put on one of the salt-poor diets, although accord- 
ing to Fischer even these cases need to have water in large 
amounts which if given by rectum and combined with sodium 
chloride and sodium carbonate, as already stated, reduce the 
general body acidity and results in the disappearance of the 
edema. As yet this plan has not met with general acceptance, 
although there are some favorable reports. 

Most of the acute cases complicating or following infectious 
diseases fortunately clear up with care and gradually they 
may be returned to a normal diet, taking care for months that 
all irritants are excluded from the diet, such as much meat or 
meat soup, celery, garlic and onion, which on account of irri- 
tating oils are injurious. Alcohol is best left absolutely alone 



404 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

and is not to be recommended for any purpose. If patients 
refuse to do entirely without alcohol, some of the light white 
or red wines when diluted with carbonated waters are prefer- 
able, but strong liquors, beers and ales should not be taken 
under any circumstances. 

Certain cases of acute nephritis, particularly those of idio- 
pathic or unknown origin tend to continue indefinitely and 
trail off into a subacute condition or one that becomes chronic. 
These, in their early stages are treated as are the other acute 
cases and when they may be said to have become chronic they 
follow the dietary rules of that class. 

Diet and Treatment for Acute Toxic Nephritis from Mercury 
Poisoning. — Mercury is not infrequently taken with suicidal 
intent or by mistake for headache tablets; unless the poison is 
at once removed a severe form of toxic nephritis is set up if 
the dose is large, resulting eventually in complete anuria, 
coma and death unless relieved. The following treatment for 
these cases has been devised by Lambert and Patterson^ on 
the basis of laboratory experimentation of K. C. Vogel. 

The first indication is to give the patient the whites of 
several eggs as soon as it is known that mercury has been 
taken unless it is possible to perform lavage at once, which 
should of course be done, leaving in a pint of milk after the 
lavage. 

The following routine is instituted as soon as the patient 
ceases to vomit, the termination of which may be hastened 
by regular lavage. 

1. *^ Every other hour the patient is given 250 c.c. (8 ounces) 
of this mixture: Potassium bitartrate, 4 gm. (i dram); sugar, 
4 gm. (i dram); lactose, 15 gm. (^ oz.); lemon juice, 30 c.c. 
(i oz.); boiled water, 500 c.c. (16 oz.). Eight ounces of milk 
are given every alternate hour." 

2. The drop method of rectal irrigation with a solution of 
potassium acetate, 4 gm. (i dram) to the pint (500 c.c.) is given 
continuously. The amounts of urine secreted under this treat- 
ment are often very large. 

3. The stomach is washed out twice daily. 

4. The colon is irrigated twice daily in order to wash out 
whatever poison has been eliminated that way. 

5. The patient is given a daily sweat in a hot pack. 

The colonic drip enteroclysis is kept up day and night with- 
out interruption. When one dose of mercury has been taken, 
the treatment may be stopped after two negative examina- 
tions of the urine for mercury. For the less severe cases treat- 

1 Lambert and Patterson: Arch. Int. Med., November, 1915, p. 870. 



NEPHRITIS 405 

ment had best be kept up for one week. When large or repeated 
doses have been taken or where an old kidney disease is 
present the treatment should be kept up for three weeks, as 
the mercury is very slowly eliminated by the kidneys, stomach 
and bowel. 

Chronic Nephritis. — The diet in chronic nephritis in its 
various forms is a trying matter, for the cases are apt to run 
for years with occasional acute exacerbations, and great care 
is constantly required in order to prevent the recurrence of 
symptoms from injudicious diet and hygiene. In the acute 
cases of nephritis dieting is more stringent but of compara- 
tively short duration and the need for long-continued watch- 
fulness is less imperative. The dietary treatment of the acute 
exacerbations, occurring in the course of chronic nephritis, is 
the same as in the acute cases and afterward the cases must be 
fed and managed with the idea in mind that they may live a 
fairly long life. 

Before turning directly to the subject of specific diets it 
seems worth while to give some attention in a short para- 
graph to the general management of chronic nephritis from a 
dietetic point of view. 

Dietetic Management of Chronic Nephritis. — i . As most cases 
of chronic nephritis have distinct limitations in regard to their 
excretory power of nitrogen, salts and water, it is absolutely 
necessary for their most intelligent dietary treatment that 
these limitations be determined, at least approximately. 

2. Since in these cases diet is a matter of months or years, 
it is necessary to make sure that any diet chosen is palatable, 
supplies the full requirements in protein, fat, carbohydrate 
and calories adjusted to the requirements of the particular 
case and avoiding undue increase in weight. 

3. In the long-standing cases it is not necessary to exclude 
meat absolutely except possibly in the cases with high arterial 
tension. Most authorities agree with Hare^ in thinking that 
the removal of red meat from the diet for a long period is 
harmful. Since it is the extractives which seem to contain 
the pressor substances, meat soups are much better excluded 
from the diet and boiled meat is more to be desired than 
meat broiled or roasted, as the boiling removes a large pro- 
portion of the extractives. Boiling in two waters is better 
still. 

4. The diet, so far as possible, must be kept laxative, as 
many cases of chronic nephritis are made distinctly worse 
when there is constipation. 

^ Therapeutic Gazette, 19 14, p. 615. 



406 DISEASES OF THE GEN I TO-URINARY SYSTEM 

5. Von Noorden recommends once a week the giving of an 
extra one or two liters of water for the sake of its flushing 
effect. On these days the food is best Hmited to not over 
half the usual allowance. Of course when the patient is not 
excreting the ordinary daily allowance of water, it would be 
of doubtful utility to give this extra amount, although again 
Fischer insists that a kidney that is not secreting water in 
normal amount needs more water, provided it contains the 
necessary salts and alkali. 

Diets in Chronic Nephritis. — When in chronic nephritis there 
are no particular evidences of renal insufficiency, the diet 
should be distinctly of a prophylactic nature and should con- 
tain only the mild foods and unirritating substances. Such a 
diet may contain: 

Oysters, fresh fish, cream soups, vegetable purees made 
without meat stock. Eggs in limited number, not over one 
or two a day. Green vegetables, exclusive of those already 
mentioned as irritating to the kidneys. Fruits of all sorts. 
Meat, a little once a day (if there exists no contra-indication in 
hypertension) simply prepared. There is little difference 
between light meat or dark meat, mammalian meat, or that 
of fowl, except that the latter probably contains a lower per- 
centage of extractives. Fats, butter and oil, mild cheese, fari- 
naceous products such as cereals, breads, preferably stale, 
simple puddings and desserts. Milk, cream. Vichy, cider if 
sweet, grape juice or other unfermented fruit juices. Tea and 
coffee in moderation, avoiding other articles likely to disturb 
digestion. Alcohol has been disposed of under acute nephritis 
and what was said there applies equally to chronic nephritis 
and needs no discussion — it should not be used. 

Diet for Cases with Nitrogen Retention (Chronic Uremia). — In 
these individuals there is the very distinct indication to feed 
small quantities of concentrated food with low total nitrogen 
content. Miller^ recommends for this purpose cream in a 
total daily amount of one pint, or one quart half milk, half 
cream. This pint of cream furnishes 12.5 gm. protein, 92.5 
gm. fat, 22.5 gm. carbohydrate and about 1000 calories, or 
for the quart of half milk — half cream, protein 29 gm., fat 112 
gm., carbohydrate 47 gm., 1350 calories; to be sure an amount 
entirely inadequate to the general nutritional needs but suffi- 
cient for temporary use. These cases of chronic or acute 
uremia often do surprisingly well on this diet for a few days, 
extra water being allowed and given by mouth, hypodermo- 
clysis, rectum or intravenously, with or without venesection. 

1 Miller: Forchheimer's Therapeutics, vol. iv. 



NEPHRITIS 407 

Nothnagel praises a milk diet in these uremic or "near 
uremic" conditions and recommends a liter of milk in twenty- 
four hours, then when better, increasing it to one and a half 
to two and a half liters per day. This is carried out for two 
weeks when the conditions are acute. At all other times an 
exclusive milk diet is unsuitable, but should constitute a 
considerable proportion of the daily ration plus vegetables, 
fruits and farinaceous foods. 

This condition of uremia with failure of nitrogen excretion 
Fischer ascribes to extreme renal acidosis and this condition 
of acidosis unquestionably exists as proven by estimations of 
CO2 in the expired air. Acting on this theory cases are given 
alkalis by mouth, rectum or intravenously, often with marked 
benefit (.^) in the diminution of the uremic symptoms. 

When the immediate danger of uremic coma or convulsions 
is past one may increase the quantity of milk allowed, adding 
cereals at first, then vegetables, etc., gradually building up 
the diet unless there are contra-indications on account of an 
existing edema with salt retention or water retention or both, 
when the limitations of diet for these conditions must be 
observed. 

In nephritis with nitrogen retention, but without difficulty 
in water elimination, Foster has shown it is often advantageous 
to push the water ingestion up to 3000 to 4000 c.c, (3 or 4 
quarts), as in this way more nitrogen is swept out, for such 
patients cannot concentrate their urine and the only way of 
accomplishing elimination is by this method. One prerequisite, 
however, is a fairly competent circulatory apparatus. 

Diet in Water Retention. Edema. — This seldom occurs alone 
but is usually a part of a total picture of sodium chloride and 
water retention together. It was formerly thought that the 
water retention was primary, but later the chloride retention 
assumed the leading role and the water retention went with 
it hand in hand in order to keep the chlorides at their normal 
concentration of a 0.6 to 0,9 per cent, solution. In these cases 
the salt-poor diets are often useful, or the Karell diet may be 
used to advantage. 

The details of this latter are as follows: 

For first five to seven days: 200 c.c. (6^ oz.) milk every four 
hours, at 8, 12, 4 and 8. No other fluids allowed. 

Eighth day: Milk as above and in addition, 
10 A.M. One soft-boiled egg. 
6 P.M. Two pieces of dry toast. 
Ninth day: Milk as above and in addition, 

10 A.M. One soft-boiled egg and two pieces dry toast. 
6 P.M. One soft-boiled egg and two pieces dry toast. 



408 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

Tenth day: Milk as above and in addition, 

12 NOON. Chopped meat (?), rice boiled in milk, vege- 
tables. 
6 P.M. One soft-boiled egg. 

Eleventh and Twelfth days, same as tenth day. 

No salt is used at all throughout the diet. Salt-free toast 
and butter used. Small amounts of cracked ice are allowed 
with the diet. 

This method gives the kidney little water to excrete and 
later it may resume secretion probably as a result of its rest. 
On the other hand, cases are sometimes seen in which the 
fluids have been limited to 8oo to looo c.c. (27 to 33 oz.) 
but without therapeutic success, improve as soon as water is 
pushed, giving an extra 2000 c.c. or even more. 

Diet in Salt Retention. — Although this has been discussed 
slightly in connection with acute nephritis, it is in the chronic 
forms that we are apt to meet the long-standing and persistent 
cases with edema, due to chloride retention, accompanied of 
course by water retention and where some form of diet poor 
in salt is indicated. Having determined the daily output of 
salt on a fixed salt diet, as well as the elimination time for some 
definite extra amount of salt, say 10 gm., we are in a position 
to know what form of salt-poor diet is indicated. Where no 
means exist for determining the chloride excretion it may be 
concluded with considerable confidence that when one finds 
edema complicating nephritis, in the presence of a fairly com- 
petent heart, it is due to primary chloride retention. 

If one finds sufficient indication for the use of milk from the 
character of the urine, e. g., much albumin, blood cells and 
casts, we can remember that the chloride content of one liter 
of milk is 1.6 gm., and if one uses the Karell diet of course in 
the 800 c.c. there would be only 1.2 gm. of salt for the first 
few days of milk. When it is not necessary to use solely a 
milk diet even for a few days one can make use to advantage 
of one of die salt-poor diets, beginning with No. i, then No. 2 
or No. 3, gradually working toward a modified normal dietary 
exclusive of the renal irritants. 

In using the salt-poor diets it is necessary to keep in mind 
the fact that many cases in whom the edema is due unques- 
tionably to chloride retention do not begin to clear up on the 
salt-poor diet as rapidly as one could wish or might expect, 
but that in many instances the diet has to be continued for a 
week or longer before the rapid emptying of the tissues of 
salt and water takes place. Still other cases are even more 
resistant. 

The explanation of this fact is not always clear but it seems 



NEPHRITIS 



409 



likely that sparing the kidney for some time finally results in 
a restoration of its power to excrete salt. 

While these salt-poor diets are primarily designed for use 
in the diet of nephritis, other conditions accompanied by 
edema, such as chronic cardiac diseases, are often greatly 
benefited, and in fact collections of fluid in the serous cavities 
are frequently favorably influenced by one or another of these 
forms of salt-poor diet. 

In this diet, the cereals — butter, bread, etc. — used are.all prepared without salt. 



Salt- POOR Diet No. i. 

Breakfast. Gm. 

Farina 60 

Bread 30 

Butter (unsalted) 30 

Sugar N .... 10 

Egg (i) 40 

Coffee 175 

Prunes, stewed 60 



Oz. 
2 
I 
I 

5! 
2 



Dinner. 





Gm. 


Oz. 


Rice .... 


60 


2 


Farina 


100 


^^ 


Bread . . . 


30 


I 


Butter (unsalted) 


20 


f 


Sugar 


ID 


i 


Tea ... . 


175 


5i 



. 405 

Supper. 

Toast . . . 
Egg (I) . . 
Bread . 
Butter (unsalted) 
Sugar . 
Custard 
Baked apple 
Tea .... 



I3i 



Gm. 

15 
40 
30 
15 
ID 
100 
60 



Oz. 
1 
2 

I 
1 
2 
1 

3I 

2 

5f 



395 13 445 I4f 

This contains chlorides i gm. (approximately); protein 36 gm. (i^ oz.); fat, 65 
gm. (2I oz.); carbohydrate, 160 gm. (5^ oz.); calories, 1350. 



Salt-poor Diet No. 2. 



Breakfast. 








Gm. 


Oz 


Egg (I) .... 


40 


I^ 


Farina .... 


60 


2 


Bread .... 


65 


2l 


Butter (unsalted) . 


30 


I 


Coffee .... 


175 


sf 


Prunes or baked 






apple .... 


60 


2 



Dinner. 



Egg (I) . . 
Bread . 
Butter (unsalted) 
Farina . 
Sugar . 
Rice ' . . . 
Tea .... 



Gm. 
40 
60 

35 
100 

ID 

60 

175 



Oz. 
li 
2 

T 1 

A 6 

3i 



i5i 



430 14 480 

Supper. Gm. Oz. 

Toast 15 I 

Egg (i) 40 If 

Butter (unsalted) 30 i 

Bread 60 2 

Custard 100 3^ 

Baked apple 60 2 

Prunes 60 2 

Tea 175 jf 

540 175 

This contains chlorides 1.4 gm. (approximately). Protein, 51 gm. (if oz.); 
fat, 100 gm. (35 oz.); carbohydrate, 250 gm. (8^ oz.); calories, 2150. 



410 DISEASES OF THE GEN ITO -URINARY SYSTEM 



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O CO 01 o 



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lO 

o« O 

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o lo "^ 



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vO M O 


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NEPHRITIS 



411 



Salt-poor Diet No. 4.^ 





Breakfast. 


Oatmeal (cook 
Oatmeal (raw) 
Eggs . . 
Coffee . . 


3d) 150 gm 
25 gm 

200 c.c. 


Bread . 
Butter . 




40 gm 
31 gm 


Sugar . 




10 gm 



Supper. 

Eggs (2) . . 80 gm. 

Prunes ... 50 gm. 

Rice (cooked) . 150 gm. 

Rice (raw) . . 25 gm. 

Cream ... 50 c.c. 

Tea .... 200 c.c. 

Bread ... 30 gm. 
Butter (unsalted) 31 gm. 

Sugar ... 7 gm. 

623 gm. 



5 oz- 
I oz. 

6^ oz. 

\\ oz. 

I oz. 

\ oz. 



456 gm. 14! oz. 



if oz. 
if oz. 
5 oz- 

6 OZ. 
if OZ. 

6| oz. 
I oz. 
I oz. 

\ OZ. 

16 oz. 



Potato . 

Tomato 
Steak . . 
Broth . . 
Bread . 
Butter 
(unsalted) 



Dinner. 

100 gm. 

100 gm. 
120 gm. 
200 c.c. 

30 gm. 

31 gm. 



581 gm. 



This Diet Contains: 



Protein 
Fat . 
Carbohy- 
drate 
NaCl 
Fluids 
Nitrogen 
Calories 



64.8 gm. 
124.7 gm. 
140. 1 gm. 

0.9 gm. 
650.0 c.c. 
10.3 gm. 
2000 . o 



33 oz. 

3i oz. 
4 oz. 
6| oz. 
I oz. 

I oz. 

19 oz. 



2 oz. 
4 oz. 
42 oz. 

3 oz. 

2\\ oz. 

I oz. 



Bread, butter, sugar, may be given as desired, providing total is unchanged. 



Table of Salt Content of Common Foods. 

Per cent. 

Milk 0.18 

Beef broth o . 735 

I egg 0.086 

Chicken broth 0.35 

Pea soup o . 499 

Ordinary white bread (not salt-free) . . . . 0.701 

Rice 0.748 

Boiled potato o . 058 

Chicken o.oi 

Beef 0.04 

Lamb chops o . 97 

Pickerel . o. 10 

Cod .' . 0.59 

Salmon 0.46 

Haddock 0.59 

Oatmeal gruel 0.075 

Macaroni 0.07 

Beans 0.0058 

Carrots 0.029 

Apple sauce 0.0025 

For full list of salt in foods see Table, p. 81. 



(Coleman) 



Schall-Heisler 



Constructed by Miss A. S. Foster, Dietitian to the Department of Diseases 
of Metabolism, Presbyterian Hospital, N. Y. 



412 DISEASES OF THE GEN ITO-VRT NARY SYSTEM 



General Protein Contents of Some Foods. 



Per cent. 
7.0 to 12 

23.0 to 25 
6.0 to 8 
3.0 to 



3.0 to 
2.0 to 
about 
0.3 to 
2.8 



22.0 to 29 



Cereals contain 

Peas and beans 

Breads .... 

Puddings 

Soups .... 

Pea, bean, cream soups 

Green vegetables . 

Root vegetables 

Fruits .... 

Cream cheese 

Stilton 1 

Swiss I 

Edam | ' ' ' 

Holland J 

Conclusion. — ^Thus it will be seen that if care is taken in 
determining the type of nephritis, whether acute or chronic, 
and as well, which of the functions are principally disturbed, 
much can be done by dietary regulation to spare a diseased 
kidney unnecessary labor, and at the same time furnish the 
organism with the food distinctly appropriate to the needs of 
each individual case. 

PYELITIS. 

Whatever the cause of the irritation in the pelvis of the 
kidney may be, whether from calculus or infection, the dietetic 
indications are plain enough. As soon as the trouble is recog- 
nized the patient should be put on a milk diet with a certain 
allowance of farinaceous gruel and large amounts of water 
urged, either as plain water or mild, alkaline drinks, such as 
Vichy or Vichy and water, equal parts, or water with i gm. 
or 15 grains of bicarbonate of soda added to each glassful. (If 
urotropin is used to combat the infection, nothing should be 
used to reduce the natural acidity of the urine, as this drug is 
only decomposed in an acid medium.) As soon as the fever is 
over one may give a lactofarinaceous diet with green vege- 
tables and later return to a mixed diet, but with the meat 
strictly limited to a very small portion, not more than once a 
day. No condiments of any kind should be allowed and alcohol 
in every form is contra-indicated. 

If nephritis occurs as a complication of the infection the 
diet should be regulated in much the same way except that 
the return to mixed feeding should be delayed until all signs 
of the acute process in the kidney substance have subsided. 
Attention must be given to preventing constipation, and for 
this purpose some of the mild saline laxative waters may be 



Forchheimcr's Therapeutics, iv, 42. 



GONORRHEA 413 

used or aloes and podophylin, cascara, etc. If edema develops 
as a consequence of nephritis it will be necessary to make 
use of one or other of the salt-poor diets, as detailed under 
nephritis. 

One important fact to remember is, that a continued flush- 
ing of the kidney pelvis by large quantities of ingested fluid 
removes the products of irritation and helps greatly in the 
heaHng process. 

CYSTITIS. 

Practically the same dietetic rules given for pyelitis hold 
good in cystitis, for the difi^erence in the location of the infec- 
tion does not cause any change in the dietetic requirements. 
A bland diet at first, largely fluid, and always containing con- 
siderable amounts of liquid, is the factor of chief importance; 
the same abstinence in the use of alcohol and condiments or 
irritants is observed as in pyelitis. 



GONORRHEA. 

Even with a specific infection of the anterior and posterior 
urethra and possibly the complicating cystitis and prosta- 
titis the diet conforms very largely to that already recom- 
mended for pyelitis and cystitis. In the early stages a milk 
diet for a few days, to reduce the irritation, combined with 
alkaline drinks, to change the reaction of the urine to alka- 
line, will make the patients much more comfortable. The diet 
may then be enlarged by the use of all farinaceous and vege- 
table foods, eggs, milk products, cheese, etc., and, when the 
inflammatory process reaches the subacute stage, the addition 
of meat once a day is entirely allowable. 

Foods to be particularly avoided are: all forms of spiced and 
highly seasoned food and condiments, alcohol in any form 
whatever, strong tea and coff'ee, acid fruits, tomatoes and 
asparagus. 

It should be remembered that a discharge that is almost 
cured may be readily started again by an indulgence in irritat- 
ing foods or drink. This is especially true of the use of alco- 
hol. If it should seem necessary for any reason to take some 
form of alcoholic drink, a diluted light claret or white wine is 
best, using an alkaline water, such as Vichy or ApoUinaris 
as a diluent. However, too much stress cannot be laid upon 
the avoidance of any alcohol. 



414 DISEASES OF THE GEN ITO-URI NARY SYSTEM 

NEPHROLITHIASIS. 

The majority of calculi belong to one of three classes, uric 
acid, phosphates or oxalates. Uric acid and oxalate calculi 
are found in acid urine, phosphatic calculi in alkaline urine 
and these latter are more apt to come secondary to infection 
and fermentation. 

The diet must be simple, avoiding all rich foods and sauces 
or a great variety at one meal and should be sufficient for the 
needs of the body but with no surplus. 

If the stone is of uric acid, a purine-free or low purine diet 
should be insisted upon, omitting meats, particularly gland- 
ular organs and soups and all highly seasoned foods. Sugar 
and fat may be taken moderately. 

When the stone is of the oxalate variety all the foods that 
contain oxalic acid in excess should be left out of the diet, 
notably strawberries, rhubarb, figs, apples, peas and spinach. 
Most of the other vegetables except beans and peas are also 
best left alone, as they all contain an excess of lime, rendering 
the oxalate more insoluble. 

Meat, in all except glandular form, is allowed freely. This 
same general dietary rule holds for phosphatic calculi. 

In all but phosphatic stones the use of alkaline mineral 
waters is allowed and does good not by virtue of dissolving 
the stone but by flushing the kidneys, rendering the urine less 
acid with the consequent lessened chance of further calcareous 
deposit. 

It is best to keep the urine faintly acid or neutral but not 
alkaline, in the latter instance it favors the deposit of phos- 
phates either as calculi or as a coating to a uric acid calculus. 

Water in large amounts is recommended to dilute the urine 
and flush the kidneys, so preventing much of the further 
deposition of salts. 

AMYLOID KIDNEY. 

There are no special indications for diet in this condition 
so far as the amyloid disease itself is concerned, but since in 
this condition the excretory power of the tubules is diminished 
the nitrogenous foods should be kept at rather a low point, 
40 to 60 gm. (ij to 2 oz.), per day while the total food value 
of the diet should be high to help combat the chronic infection 
almost always present somewhere in the body, which is the 
active cause of the amyloid degeneration. 



CHAPTER XXV. 

DISEASES OR PATHOLOGICAL STATES DUE TO 
DISTURBANCES OF NORMAL METABOLISM. 

Of course in all diseases there are disturbances of metabo- 
lism, so in setting apart a classification such as this we mean 
merely that in the following diseases the abnormal anabolism 
or catabolism assumes the chief role, notwithstanding every- 
thing else. On this account it is not always easy to say just 
which diseases shall be included in this class, and as in the 
other classifications it is more than probable that a certain 
amount of rearrangement will be necessary as time passes. 

In all these states the resultant conditions are more com- 
parable to the results of hyperfunction or hypofunction of 
certain sets of glands which control growth and body exchange, 
rather than to actual disease, although the line is often not 
sharply drawn between the two, for that which starts merely 
as a functional disturbance may progress to the proportions of 
a fatal disease, e. g., alimentary glycosuria and severe diabetes. 

DIABETES INSIPIDUS. 

This disease, characterized by the passage of large amounts 
of urine of low specific gravity, is probably due to a functional 
or organic disease of the brain and there is also a possibility 
that the center in the medulla which controls the renal blood 
supply as well as excretion, is affected.^ 

Disease in or about the hypophysis is often associated with 
diabetes insipidus and Frank^ has suggested the theory that 
excessive function of this gland is the cause of the disease. 
The injection of pituitrin often helps these cases, which would 
rather make it seem as if a hypofunction of the gland were 
more probable than excessive secretion. 

"Minkowski^ advises that the amount of chlorides and spe- 
cific gravity of the urine be determined after the ingestion of 
considerable salt. If both increase relatively more than the 
urine does, he believes that the power of excreting a concen- 
trated urine is still possessed by the kidneys. Therefore 

1 Ref. Handbook Med. Sc, 3d ed., p. 516. 

2 Berl. klin. Wchnschr., xlix, 9. 

^ Therapeutic die Gag., 19 10, p. i. 



416 DISTURBANCES OF NORMAL METABOLISM 

diminishing the amount of water drunk by the patients will 
help them. If the amount of urine increases, relatively the 
more a salt-free diet and one poor in protein will be a help." 
In choosing a diet it is necessary to avoid foods that cause 
indigestion or flatulence, particular restriction being placed 
on sugar, for when an excess of this is taken it tends to raise 
the percentage of sugar in the blood, which aggravates the 
polyuria. Cold drinks which are diuretic must be given up, 
as cold milk, beer, cider, also watery fruits. A salt-poor and 
low protein diet tends to diminish the quantity of urine when 
the kidneys do not concentrate the urine normally. 

DIABETES MELLITUS. 

In perhaps no other disease is diet such a matter of vital 
importance as in diabetes mellitus, for as time has gone on 
and one after another procedure or drug has been vaunted as 
a cure only to be cast aside as entirely wanting, diet has 
remained as the one factor which is capable, if properly 
employed, of resting the glycogenic function of the liver, and 
in all but the most severe and necessarily fatal cases is also 
capable of bringing about a condition more or less approach- 
ing the normal. By its proper employment the mild cases are 
clinically cured, the moderately severe are rendered mild and 
the most of the very severe are changed to cases of moderate 
severity. 

An extended discussion of the pathological physiology and 
disturbed metabolism of diabetes is not necessarily a part of 
a book on dietetics but it is necessary to discuss the important 
changes of metabolism if one is to appreciate, to even a small 
degree, the importance and significance of diet in the varying 
phases of this disease. 

Interest naturally centers about carbohydrate metabolism 
which formerly was thought to be the only matter of impor- 
tance and that the metabolism of protein and fat in no way 
entered into the question for the diabetic. Following this, the 
importance of fats in the production of acidosis was discovered, 
and last of all the fact that the body could synthetize sugar 
out of protein. With this last the whole question of diet in 
diabetes was revolutionized at a stroke and an explanation 
was at hand as to why certain cases failed to become sugar- 
free on a meat-fat diet. Another significant change of thought 
has been that formerly attention was focussed on the glyco- 
suria as the most important index of a disturbed sugar metab- 
olism, whereas now the hyperglycemia, which always accom- 
panies glycosuria, except in the few cases of so-called renal 



DIABETES MELLITUS 417 

diabetes, occupies chief attention, since it is found that many 
cases of diabetes get rid of their glycosuria and would formerly 
have been pronounced cured but are found to retain their 
hyperglycemia, thus still showing evidence of a disturbed 
sugar metabolism. 

When we come to study the various aspects of the sugar 
question we do not find unanimity of opinion. Claude Ber- 
nard, Lowe and von Noorden believing that diabetes is due 
to disturbance of sugar production, while Naunyn and Min- 
kowski believe it due to a disturbance of sugar burning. ^ 
Hepatic disorders or pathological states were blamed in time 
past while now the liver is believed by most to be httle more 
than the organ which stores sugar or glycogen and is "played 
upon" so to speak, by other organs by which the process of 
sugar excretion by the liver is stimulated or depressed. If 
we will refresh our memories by reference to normal physi- 
ology, and then its application to diseased states, we will get 
a better idea of the question which is so well put by von 
Noorden. 2 

The liver is the organ which renders sugar available for an 
immediate source of energy and maintains the sugar content 
of the blood at 0.075 ^^ o.i per cent. If the liver produces 
more sugar than is required by the tissues, there is an increased 
amount of it in the blood (hyperglycemia) under which condi- 
tion some escapes in the urine. If, on the other hand, the liver 
does not supply enough sugar to the blood, the muscles are 
the first to suffer and the individual feels fatigue, as occurs 
after severe labor. 

In a condition of alimentary glycosuria the amount of sugar 
ingested is excessive and cannot be used up, so is excreted in 
the urme. In order to prevent this, however, the liver stores 
the sugar as insoluble glycogen which forms a reserve sup- 
ply. By the action of glycogenase, also found in large amounts 
in the liver and more or less universally in the body, the glyco- 
gen is reconverted into soluable sugar again and so goes into 
the blood. If for any reason the ordinary supply of carbo- 
hydrate is withheld the liver can form sugar out of protein 
and fat. 

In health the supply and demand for sugar in the blood are 
exactly balanced and regulated, i. e., the liver does not split 
up more glycogen for the use of the body than necessary. 
There are at least two factors which according to von Noorden 
influence the function of sugar making, viz., the pancreas and 
the suprarenals, the former a depressant, the latter excitants to 

^ Berl. klin. Wchnschr., 1913, p. 2161. 
2 Am. Jour. Med. Sc, 19 13, cxlv, i. 
27 



418 



DISTURBANCES OF NORMAL METABOLISM 



sugar formation. According to this theory, from the pancreas 
there goes to the hver a specific secretion (an internal secre- 
tion, presumably from the islands of Langerhans) which acts 
as a depressant to sugar formation in the liver. If the pan- 
creas is removed, so is this break in sugar production, and the 
diastase acting unhindered causes an excessive sugar output 
from the liver, which is excreted in the urine. This, von 
Noorden says, is really a severe diabetes. 

Adrenalin excites the production of sugar by the liver and a 
small amount of it is constantly being excreted by the supra- 
renals and absorbed by the blood. Therefore the supra- 
renals antagonize the action of the pancreas in its relation to 
sugar production and these two glandular systems really con- 
trol the sugar production by the diastase in the liver. The 
suprarenals do not act alone, for "they are especially under 
the control of the nervous system." The Claude Bernard 
center in the medulla is the point from which go out impulses 
that stimulate the suprarenals to hyperfunction through the 
sympathetic nerves and thereby cause glycosuria. The pan- 
creas is not independent either, for it is under the control of 
the thyroid and when the thyroid overfunctionates the pan- 
creatic function is paralyzed and the glycogenase in the liver 
again acts unhindered, resulting in the overproduction of 
sugar and glycosuria. So in Graves's disease we see glycosuria 
and in myxedema increased sugar tolerance. The pancreas is 
also probably affected by other factors as yet unknown. 

This theory is vizualized by the following diagram. The 
arrows represent the direction of the stimuli and the plus or 
minus signs whether the stimulus is an excitant or depressant 
on the next organ. 




Intestines 



Panorcas 



Adrenals etc. 



DIABETES MELLITUS 419 

Besides the disturbance in carbohydrate metaboHsm we have 
to consider carefully that of protein and fat. 

The Relation of Protein Metabolism to Glycosuria. — 
Protein metabolism in the mild forms of diabetes probably 
proceeds normally and requires no further discussion, but in 
the more severe varieties we have other factors that must be 
taken into consideration. In 191 3 Cammidge^ called attention 
to the fact that in estimating the degree of toxicosis in diabetes, 
one should take into consideration the complete picture and 
that three stages should be distinguished. In two of the three 
"the defect in metabolism is confined to a more or less com- 
plete inability to make use of the sugar derived from the carbo- 
hydrate foods, but amino-acids are still available as a source 
of energy and the body makes use of these supplemented in 
the milder forms by a certain amount of sugar derived from 
starchy foods and fats, for its needs. In the third form, to 
which the name Miabetes' is confined by some writers, the 
power to metabolize amino-acids is diminished, with the result 
that these bodies appear in the urine and gradually increase 
in amount as the metabolic defect becomes more pronounced. 
Even in the most serious cases, however, some of the amino- 
acids are diaminized and converted into dextrose, thus con- 
tributing to the sugar excreted in the urine, while the fatty 
acids of others are imperfectly oxidized and give rise to the 
'acetone bodies' (acetone, aceto-acetic acid and |8-hydroxy- 
butyric acid) that are passed at the same time. Estimations 
of the amino-acids, 'acetone bodies' and sugar give therefore 
a much more complete picture of the state of the metabolism 
than any one of these taken alone, and by considering them in 
conjunction with the effects produced by a diet of which the 
qualitative and quantitative composition is known, we can 
determine the stage that has been reached and the probable 
expectation of life." 

These findings go with the clinical observation that when 
the diabetes is severe, the protein should be curtailed and 
intervals of a meat-free diet given. 

Animal food is rich in those forms of protein which the dis- 
turbed organism finds it difficult to break down and utilize, 
while vegetable proteins are poor in these constituents and a 
larger proportion of amino-acids which can be made use of to 
supply the energy needed by the tissues. Egg protein is more 
like vegetable protein in this respect and can be used safely 
where other animal protein is forbidden. Milk, however, is 
like the meat protein. 

^ Lancet, 1913, ii, 1319. 



420 DISTURBANCES OF NORMAL METABOLISM 

When we find a patient with amino-acids in the urine we 
must determine whether they are from the food or from break- 
ing down of their own tissues and if from the food whether 
they can still take care of the protein from egg and vegetable. 
If omitting animal proteins results in freeing the urine of 
amino-acids, as is the case in gout, the prognosis is better and 
the outlook- with proper diet of getting rid of glycosuria is 
good, but if we are not able, by regulating the diet, to get rid of 
the amino-acids the outlook is poor. This constitutes the 
third or true diabetic stage. 

The Nitrogen Balance in Diabetes. — Cammidge^ in calcu- 
lating the intake and output of nitrogen in a severe case of 
diabetes found that with an intake of 12 gm. nitrogen and 52 
gm. carbohydrate, the urine showed 31.8 gm. nitrogen with 
high acetone bodies, ammonia nitrogen, calcium and mag- 
nesium and 229 gm. sugar. This demonstrated that the patient 
was forming sugar from his own tissues. This together with 
the abnormal excretion of amino-acids, uric acid and creatinin 
showed that there was a high degree of tissue waste accom- 
panied by defective protein metabolism. When in this case 
the nitrogen intake was reduced to 3 gm. still keeping the 
sugar value of the diet at nearly the same level, resulted in the 
fall of sugar excretion to less than one-half its former amount, 
the blood sugar fell from 0.3 to 0.2 per cent, and the alveolar 
carbon dioxide rose to 4.6 per cent, from 0.75 per cent, before; 
the /3-oxybutyric acid also fell from 19.7 to 3.6 gm. accompanied 
by a clinical improvement. Sufficient has been said to leave 
no doubt in the mind that the sugar excretion is markedly 
influenced by protein metabolism and that it is not possible in 
• severe diabetes to make up a deficiency of carbohydrate in the 
diet by feeding large amounts of protein. Until this fact was 
learned it was not understood why a diabetic continued to 
excrete sugar on a carbohydrate-free diet and that it w^as not 
until the protein was reduced or changed from a meat to an 
egg protein that the patient began to be sugar-free. 

In this connection reference should be made to coma occur- 
rmg m some cases of severe diabetes due to a perverted pro- 
tein metabolism not associated with a ketonuria. Kraus,'- 
Rumpf^ and Lepine"" and others showed that cases of dia- 
betic coma occurred without any increase of organic acids in 
the urine and Rosenbloom^ reports 3 cases of typical coma 

^ Lancet, 1915, ii, 1187. 

2 Zeit. f. Hcilk., 1906, x, 1899. 

^ Bcrl. klin. Wchnschr., 1895, xxxii, 185, 669, 700. 

* Rev. d. mod., 1887, xii, 224; 1888, xiii, 1004. 

^ New York Med. Jour., August 7, 1915. 



DIABETES MELLITUS 421 

occurring in severe diabetes with no carbohydrate tolerance, 
and even with a restricted protein intake the glycosuria was 
not diminished. They were observed weeks or months during 
all of which time the urine contained an average normal amount 
of ammonia nitrogen, no ketone bodies nor was there any 
evidence of kidney disease. All 3 cases died in typical 
diabetic coma. Here we have an effect from abnormal pro- 
tein metabolism which must be taken into account when deal- 
ing with severe diabetes, and its clinical appHcation to dietetics 
is plain. 

Relation of Fat Metabolism to Glycosuria. — As is well known 
the normal end-products of fat metabolism are water and 
CO2; the body fats are chiefly palmitic, stearic and oleic acids, 
all of which contain an even number of carbons in their respec- 
tive molecules. Although protein can add to the formation 
of acetone bodies, they arise mainly from fat. The complete 
breaking down of the fatty acids is not altogether an inde- 
pendent process, as it is largely dependent on the presence of 
carbohydrate in the diet as well upon the ability of the 
organism to metabolize carbohydrates. ^ 

Fat does not act as a stimulant to sugar production as does 
protein but is a source of sugar, although it is only used by the 
liver in making glycogen when other supplies fail. In severe 
diabetes, however, the body fat is used in large amount so result- 
ing in emaciation. 2 

In severe diabetics with no carbohydrate tolerance the buty- 
ric acid molecule formed in intermediary metabolism of the 
fatty acids becomes incompletely oxidized only to j3-oxy- 
butyric, aceto-acetic acids, and acetone which last is derived 
from the two former acids. Ringer believes that "one of the func- 
tions of the glucose molecule in normal metabolism is to make 
jS-oxybutyric acid, which arises constantly in the catabolism 
of the higher fatty acids, combustible," and he concludes that 
if we could find fats with an uneven number of carbon atoms 
they would be oxidized into glucose instead of acetone bodies. 
In these conditions of perverted fat metabolism and ketonuria, 
although we speak of acidosis, by this is meant the accumula- 
tion of acid bodies in the blood and tissues suflScient to neu- 
tralize enough of the sodium bicarbonate there present to 
reduce the alkaline reserve to a level below normal; it does not 
mean that blood and tissues become actually acid in reaction.^ 

Although ketonuria is more apt to be extreme when there 
is no carbohydrate tolerance, it is a fact that considerable 

^ Ringer: Tr. Assn. Am. Phys., 19 13, xxviii, 469. 
2 Von Noorden: Am. Jour. Med. So., 1913, cxlv, i. 
^ Stillman: Med. Rcc., 1916, Ixxxix, 390. 



422 DISTURBANCES OF NORMAL METABOLISM 

amounts of acid bodies may be excreted when the carbohy- 
drate tolerance is 20 to 30 gm. In long fasting, man shows 
a fall in his respiratory quotient while the diabetic shows some 
tendency to a rise. Such observation leads to the belief that 
the diabetic even in the severest cases burns some sugar or 
some other body substance to compensate for it. Joslin^ says 
there is much experimental evidence that the other body sub- 
stances are the acids. jS-oxybutyric acid has a high caloric 
value and yields a high respiratory quotient. 

Hyperglycemia. — Before proceeding to the discussion of diets 
in diabetes a word about hyperglycemia is in place, the various 
causes of which as given by Dock^ are as follows: 

1. Excessive ingestion of sugar. 

2. Reduction of liver function. 

3. Exaggeration of the glycolytic function of the liver. 

4. Reduction of the glycolytic function of the muscles. 

5. Exaggeration of the glycolytic function of the muscles. 

6. Reduction of formation of fat from glucose. 

7. Reduction of combustion of glucose in the muscles. 
Since in diabetes mellitus one or more of these functions 

may be disturbed we see what a various etiology of hyper- 
glycemia there may be, and it is a much more accurate index 
of perverted carbohydrate metabolism than is glycosuria. 

Dietetic Treatment of Diabetes. — ^The dietetic treatment 
of diabetes mellitus resolves itself into the questions as to how 
much carbohydrate the individual can utiHze and how a 
tolerance for carbohydrate can be obtained or increased. 

If, as Allen says, we compare the glycosuria to a gastro- 
intestinal indigestion, due to either a functional or organic dis- 
turbance, we see at once that what is needed is rest for the 
deranged function, followed by a gradual system of dietetic 
reeducation, principally so far as the carbohydrates are con- 
cerned, until step by step the body can take care of slowly 
increased amounts of this food element. 

The avoidance of overstrain of the glycogenic function 
must be kept ever in mind, for if during the process of reeduca- 
tion sufficient food is given to again precipitate the glycosuria 
this puts off the further advance disproportionately and if it is 
continued, quickly results in the loss of the bettered function 
obtained by previous careful dieting. In other words "over- 
strain weakens while rest strengthens any damaged function."^ 

In considering the details of dietetic management we have 
two principal methods of treatment, one the European, best 

^ New York Med. Jour., 1915, ci, 628. 

2 Int. Cong. Med., 6 Med., p. 234. 

3 Foster: Diabetes Mellitus, p. 183. 



DIABETES MELLITUS 423 

exemplified perhaps by the von Noorden routine, and the 
other an American method, known as Allen's fasting cure for 
diabetes. While there are of course numerous modifications 
of these methods and to a certain extent they are modifications 
of each other, the von Noorden cure puts the emphasis on 
first finding the carbohydrate tolerance, if any, by beginning 
with increasing or diminishing amounts of carbohydrate with 
a certain amount of modified starvation in severe cases, for a 
day or two. Allen's method lays stress on the fasting phase 
of the treatment, the reduction of weight of the patient and 
keeping the total caloric value of the food low when feedings 
are begun. The fats are kept particularly low, for if given in 
any considerable quantities the carbohydrate tolerance is 
reduced. The fast is persisted in until the urine becomes 
sugar-free and the ketone bodies usually drop, but do not as a 
rule disappear until the patients are fed after their fast. When 
the patient is sugar-free, carbohydrate is allowed in small 
amount and gradually increased to tolerance, quite as much 
emphasis being also put on the protein and fat tolerance in 
their relation to hyperglycemia. 

Von Noorden Method. — For a differentiation of the treatment 
we may arbitrarily divide diabetics into three classes of cases. 

1. Those in whom the sugar excretion is less than 50 gm. 
without ketonuria. 

2. Those in whom the sugar excretion is more than 50 gm. 
also without ketonuria. 

3. Those in whom the sugar excretion is more than 50 gm. 
with ketonuria.^ 

The first step is the determination of the individual's carbo- 
hydrate tolerance if such be present. In the very mild cases 
associated with overeating of s